Provider Demographics
NPI:1962554972
Name:BUCKINGHAM, CAILIE A (RD)
Entity type:Individual
Prefix:
First Name:CAILIE
Middle Name:A
Last Name:BUCKINGHAM
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 1:1345 KING ST
Mailing Address - Street 2:
Mailing Address - City:BELLINGHAM
Mailing Address - State:WA
Mailing Address - Zip Code:98229-6223
Mailing Address - Country:US
Mailing Address - Phone:360-676-1696
Mailing Address - Fax:
Practice Address - Street 1:1345 KING ST
Practice Address - Street 2:
Practice Address - City:BELLINGHAM
Practice Address - State:WA
Practice Address - Zip Code:98229-6223
Practice Address - Country:US
Practice Address - Phone:360-676-1696
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-18
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2624133V00000X
WADI60455187133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN644675000Medicaid
MN644675000Medicaid