Provider Demographics
NPI:1710270210
Name:WHITE, CAROL JEAN (RD)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:JEAN
Last Name:WHITE
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 1:15515 JUANITA WOODINVILLE WAY NE
Mailing Address - Street 2:APT C204
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-1576
Mailing Address - Country:US
Mailing Address - Phone:818-445-7852
Mailing Address - Fax:
Practice Address - Street 1:500 SW 39TH ST
Practice Address - Street 2:SUITE 150
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98057-4915
Practice Address - Country:US
Practice Address - Phone:425-264-2584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-17
Last Update Date:2011-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI 60209104133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered