Provider Demographics
NPI:1063068831
Name:DUESTERHOEFT, VICKI LYNN (MS, RDN, LD)
Entity type:Individual
Prefix:
First Name:VICKI
Middle Name:LYNN
Last Name:DUESTERHOEFT
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17025 OAKDALE RD
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-9646
Mailing Address - Country:US
Mailing Address - Phone:503-623-3112
Mailing Address - Fax:
Practice Address - Street 1:2600 CENTER ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-2669
Practice Address - Country:US
Practice Address - Phone:503-945-9826
Practice Address - Fax:503-945-9864
Is Sole Proprietor?:No
Enumeration Date:2019-08-16
Last Update Date:2019-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR000799133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR000799OtherOREGON HEALTH LICENSING BOARD OF LICENSED DIETITIANS
818835OtherCOMMISSION ON DIETETIC REGISTRATION