Provider Demographics
NPI:1639789795
Name:WHATCOTT, TISHA (RD)
Entity Type:Individual
Prefix:
First Name:TISHA
Middle Name:
Last Name:WHATCOTT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 251
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:ID
Mailing Address - Zip Code:83839-0251
Mailing Address - Country:US
Mailing Address - Phone:208-512-9028
Mailing Address - Fax:
Practice Address - Street 1:1000 E ELEP AVE
Practice Address - Street 2:
Practice Address - City:COLVILLE
Practice Address - State:WA
Practice Address - Zip Code:99114-5014
Practice Address - Country:US
Practice Address - Phone:509-684-2573
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-497133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered