Provider Demographics
NPI:1699840983
Name:CAMPBELL, NICOLE LORELEE (MPH, RD)
Entity type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:LORELEE
Last Name:CAMPBELL
Suffix:
Gender:F
Credentials:MPH, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4134 36TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98126-2620
Mailing Address - Country:US
Mailing Address - Phone:425-445-5991
Mailing Address - Fax:
Practice Address - Street 1:20 AUBURN AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98002-5404
Practice Address - Country:US
Practice Address - Phone:206-250-6855
Practice Address - Fax:206-296-8403
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001700133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8435695Medicaid