Provider Demographics
NPI:1659951366
Name:BROCK, ANALIESE N/A (RD)
Entity Type:Individual
Prefix:
First Name:ANALIESE
Middle Name:N/A
Last Name:BROCK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:ANNALIESE
Other - Middle Name:N/A
Other - Last Name:BROCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:315 WARNER ST
Mailing Address - Street 2:
Mailing Address - City:SEDRO WOOLLEY
Mailing Address - State:WA
Mailing Address - Zip Code:98284-1649
Mailing Address - Country:US
Mailing Address - Phone:206-660-4695
Mailing Address - Fax:
Practice Address - Street 1:1100 9TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98101-2756
Practice Address - Country:US
Practice Address - Phone:206-223-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-08
Last Update Date:2021-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA86133310133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered