Basic Information
| Provider Information | |||||||||
| NPI: | 1215479209 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PIVNICK | ||||||||
| FirstName: | KAELA | ||||||||
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| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 790 REMINGTON BLVD | ||||||||
| Address2: | |||||||||
| City: | BOLINGBROOK | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604404909 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6302962222 | ||||||||
| FaxNumber: | 6307599510 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 TAHOMA BLVD | ||||||||
| Address2: | STE 207 | ||||||||
| City: | YELM | ||||||||
| State: | WA | ||||||||
| PostalCode: | 985977735 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3604586400 | ||||||||
| FaxNumber: | 3604586444 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2016 | ||||||||
| LastUpdateDate: | 11/09/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DI60650422 | WA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.