Provider Demographics
NPI:1982059739
Name:WONG, MARTINA KARUNIA (MS, MPH, RD)
Entity Type:Individual
Prefix:
First Name:MARTINA
Middle Name:KARUNIA
Last Name:WONG
Suffix:
Gender:F
Credentials:MS, MPH, RD
Other - Prefix:
Other - First Name:MARTINA
Other - Middle Name:INDRASARI
Other - Last Name:KARUNIA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, MPH, RD
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:
Practice Address - Street 1:6601 220TH ST SW
Practice Address - Street 2:SUITE 1
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043-2166
Practice Address - Country:US
Practice Address - Phone:425-775-7274
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-29
Last Update Date:2016-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered