Provider Demographics
NPI:1720892185
Name:BLAKLEY, ALISSA MAUREEN (RD)
Entity type:Individual
Prefix:
First Name:ALISSA
Middle Name:MAUREEN
Last Name:BLAKLEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:ALISSA
Other - Middle Name:MAUREEN
Other - Last Name:MCCOY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3054
Mailing Address - Street 2:
Mailing Address - City:OMAK
Mailing Address - State:WA
Mailing Address - Zip Code:98841-3054
Mailing Address - Country:US
Mailing Address - Phone:509-826-1550
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 3054
Practice Address - Street 2:
Practice Address - City:OMAK
Practice Address - State:WA
Practice Address - Zip Code:98841-3054
Practice Address - Country:US
Practice Address - Phone:509-826-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-05
Last Update Date:2025-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI61645042133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered