Provider Demographics
NPI:1902539083
Name:MILES, MARISSA
Entity type:Individual
Prefix:
First Name:MARISSA
Middle Name:
Last Name:MILES
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12414 190TH AVENUE CT E
Mailing Address - Street 2:
Mailing Address - City:BONNEY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:98391-6027
Mailing Address - Country:US
Mailing Address - Phone:253-350-5913
Mailing Address - Fax:
Practice Address - Street 1:8301B 5TH AVE NE
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-4118
Practice Address - Country:US
Practice Address - Phone:206-799-7010
Practice Address - Fax:206-866-0204
Is Sole Proprietor?:No
Enumeration Date:2022-07-06
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA86277139133N00000X
133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist