Provider Demographics
NPI:1902199607
Name:LOPEZ-STICKNEY, DOMINIQUE (RD, LD)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:
Last Name:LOPEZ-STICKNEY
Suffix:
Gender:F
Credentials:RD, LD
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 1600
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98668-1600
Mailing Address - Country:US
Mailing Address - Phone:360-514-7932
Mailing Address - Fax:360-514-4233
Practice Address - Street 1:8716 E MILL PLAIN BLVD
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98664-2531
Practice Address - Country:US
Practice Address - Phone:360-514-7932
Practice Address - Fax:360-514-4233
Is Sole Proprietor?:No
Enumeration Date:2011-05-27
Last Update Date:2011-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60219698133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered