Provider Demographics
NPI:1962648238
Name:WILSON, DAWN MARIE (RD)
Entity Type:Individual
Prefix:MRS
First Name:DAWN
Middle Name:MARIE
Last Name:WILSON
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 1:3702 LONG LAKE DR SE
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-4056
Mailing Address - Country:US
Mailing Address - Phone:360-413-5962
Mailing Address - Fax:
Practice Address - Street 1:700 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5115
Practice Address - Country:US
Practice Address - Phone:360-923-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-16
Last Update Date:2008-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA953643133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered