Provider Demographics
NPI:1760816391
Name:DWAILEEBE, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:DWAILEEBE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:205 SE PARK PLAZA DRIVE
Mailing Address - Street 2:105
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684
Mailing Address - Country:US
Mailing Address - Phone:619-787-7557
Mailing Address - Fax:
Practice Address - Street 1:205 SE PARK PLAZA DRIVE
Practice Address - Street 2:105
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98684
Practice Address - Country:US
Practice Address - Phone:619-787-7557
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-30
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WANU60728766133N00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator