Provider Demographics
NPI:1215479209
Name:PIVNICK, KAELA (RD)
Entity type:Individual
Prefix:
First Name:KAELA
Middle Name:
Last Name:PIVNICK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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:630-759-9510
Practice Address - Street 1:201 TAHOMA BLVD
Practice Address - Street 2:STE 207
Practice Address - City:YELM
Practice Address - State:WA
Practice Address - Zip Code:98597-7735
Practice Address - Country:US
Practice Address - Phone:360-458-6400
Practice Address - Fax:360-458-6444
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60650422133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered