Provider Demographics
NPI:1740754928
Name:LOVE, OLIVIA RENEE (RD)
Entity Type:Individual
Prefix:
First Name:OLIVIA
Middle Name:RENEE
Last Name:LOVE
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 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:260-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:916 PACIFIC AVE
Practice Address - Street 2:
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-4147
Practice Address - Country:US
Practice Address - Phone:425-304-6165
Practice Address - Fax:425-304-6162
Is Sole Proprietor?:No
Enumeration Date:2019-01-22
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60919441133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1016264Medicaid