Provider Demographics
NPI:1265544043
Name:LENSSEN, POLLY MARY ELIZABETH (RD, CD, MS)
Entity type:Individual
Prefix:MS
First Name:POLLY
Middle Name:MARY ELIZABETH
Last Name:LENSSEN
Suffix:
Gender:F
Credentials:RD, CD, MS
Other - Prefix:MS
Other - First Name:MARY ELIZABETH
Other - Middle Name:POLLY
Other - Last Name:LENSSEN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RD, CD, MS
Mailing Address - Street 1:3902 DENSMORE AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98103-8240
Mailing Address - Country:US
Mailing Address - Phone:206-632-5411
Mailing Address - Fax:
Practice Address - Street 1:4800 SAND POINT WAY NE
Practice Address - Street 2:M/S W3726
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98105-3901
Practice Address - Country:US
Practice Address - Phone:206-987-5110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000333133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8267129Medicaid