Provider Demographics
NPI:1710079637
Name:LAVEZZO, RUTHMARIE GRAYBILL (RD CDE)
Entity Type:Individual
Prefix:MRS
First Name:RUTHMARIE
Middle Name:GRAYBILL
Last Name:LAVEZZO
Suffix:
Gender:F
Credentials:RD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:810 JASMINE
Mailing Address - Street 2:PO BOX 793
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-0793
Mailing Address - Country:US
Mailing Address - Phone:509-826-3158
Mailing Address - Fax:509-826-2200
Practice Address - Street 1:810 JASMINE
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-0793
Practice Address - Country:US
Practice Address - Phone:509-826-3158
Practice Address - Fax:509-826-2200
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001178133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8260218Medicaid