Provider Demographics
NPI:1760927073
Name:SURATOS, CELEZ (RD)
Entity Type:Individual
Prefix:
First Name:CELEZ
Middle Name:
Last Name:SURATOS
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 1:19930 BALLINGER WAY NE
Mailing Address - Street 2:
Mailing Address - City:SHORELINE
Mailing Address - State:WA
Mailing Address - Zip Code:98155-1223
Mailing Address - Country:US
Mailing Address - Phone:425-778-2220
Mailing Address - Fax:
Practice Address - Street 1:11216 SUNRISE BLVD E
Practice Address - Street 2:SUITE 209
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-8848
Practice Address - Country:US
Practice Address - Phone:425-778-2220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-12-21
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60695986133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA86006702OtherRD CERTIFICATION
WADI60695986OtherRD LICENSE