Provider Demographics
NPI:1588731715
Name:OBERG, DONNA JEAN (RD)
Entity type:Individual
Prefix:MRS
First Name:DONNA
Middle Name:JEAN
Last Name:OBERG
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 1:14111 148TH PL SE
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98059-7324
Mailing Address - Country:US
Mailing Address - Phone:206-296-4589
Mailing Address - Fax:206-296-4679
Practice Address - Street 1:2124 4TH AVE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98121-2308
Practice Address - Country:US
Practice Address - Phone:206-296-4589
Practice Address - Fax:206-296-4679
Is Sole Proprietor?:No
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001182133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8270175Medicaid