Provider Demographics
NPI:1104281948
Name:EDJLALI, ANAHID (RDN)
Entity type:Individual
Prefix:
First Name:ANAHID
Middle Name:
Last Name:EDJLALI
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17800 TALBOT RD S STE D
Mailing Address - Street 2:STE. D
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-5740
Mailing Address - Country:US
Mailing Address - Phone:425-277-9096
Mailing Address - Fax:
Practice Address - Street 1:790 REMINGTON BLVD
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440
Practice Address - Country:US
Practice Address - Phone:630-296-2223
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-21
Last Update Date:2018-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60479500133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic