Provider Demographics
NPI:1154871994
Name:CHANG, KATIE (MS, RD)
Entity type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:CHANG
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12220 113TH AVE NE
Mailing Address - Street 2:SUITE 210
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-6915
Mailing Address - Country:US
Mailing Address - Phone:425-918-2677
Mailing Address - Fax:
Practice Address - Street 1:12220 113TH AVE NE
Practice Address - Street 2:SUITE 210
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-6915
Practice Address - Country:US
Practice Address - Phone:425-287-3864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-05
Last Update Date:2022-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60499133133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered