Provider Demographics
NPI:1215279377
Name:WARNER, CONNIE KAY (MS, RD)
Entity type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:KAY
Last Name:WARNER
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 1:830 NE 47TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-2212
Mailing Address - Country:US
Mailing Address - Phone:503-215-2255
Mailing Address - Fax:
Practice Address - Street 1:830 NE 47TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-2212
Practice Address - Country:US
Practice Address - Phone:503-215-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-26
Last Update Date:2013-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-000647133V00000X
WADI 00000873133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered