Basic Information
| Provider Information | |||||||||
| NPI: | 1063998573 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANTANA | ||||||||
| FirstName: | NAEIMA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JAFARIAN NASERIZAD | ||||||||
| OtherFirstName: | NAEIMA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3600 LIND AVE SW | ||||||||
| Address2: | SUITE 100 ATTN CREDENTIALING | ||||||||
| City: | RENTON | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980574970 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256902715 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 24060 SE KENT KANGLEY RD | ||||||||
| Address2: | |||||||||
| City: | MAPLE VALLEY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980386801 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256903522 | ||||||||
| FaxNumber: | 4256909522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2018 | ||||||||
| LastUpdateDate: | 10/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 2112868 | 05 | WA | MEDICAID |