Provider Demographics
NPI:1689154932
Name:MATTSON, ROSE (MS, RD)
Entity Type:Individual
Prefix:
First Name:ROSE
Middle Name:
Last Name:MATTSON
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1770 NE JANICE WAY
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-6689
Mailing Address - Country:US
Mailing Address - Phone:907-750-3556
Mailing Address - Fax:
Practice Address - Street 1:2863 NW CROSSING DR STE 218
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-7190
Practice Address - Country:US
Practice Address - Phone:458-206-3404
Practice Address - Fax:541-550-1494
Is Sole Proprietor?:No
Enumeration Date:2018-08-16
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10466157-4901133V00000X
ORLD-D-10214126133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered