Provider Demographics
NPI:1811910755
Name:SIMON, JUDY D (RD, MS)
Entity type:Individual
Prefix:
First Name:JUDY
Middle Name:D
Last Name:SIMON
Suffix:
Gender:F
Credentials:RD, MS
Other - Prefix:
Other - First Name:JUDY
Other - Middle Name:D
Other - Last Name:GARDNER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 24366
Mailing Address - Street 2:M/S 359107
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-0366
Mailing Address - Country:US
Mailing Address - Phone:206-598-8920
Mailing Address - Fax:206-598-7663
Practice Address - Street 1:4245 ROOSEVELT WAY
Practice Address - Street 2:BOX 356057
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98195-0001
Practice Address - Country:US
Practice Address - Phone:206-598-4055
Practice Address - Fax:206-598-5792
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001314133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAAB37873Medicare PIN
P54963Medicare UPIN