Provider Demographics
NPI:1649540345
Name:BULLOCK, LINDSAY PAIGE (RD)
Entity type:Individual
Prefix:
First Name:LINDSAY
Middle Name:PAIGE
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:LINDSAY
Other - Middle Name:PAIGE
Other - Last Name:MCDANIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:519 NW QUINCY PL
Mailing Address - Street 2:
Mailing Address - City:CHEHALIS
Mailing Address - State:WA
Mailing Address - Zip Code:98532-1629
Mailing Address - Country:US
Mailing Address - Phone:360-736-6778
Mailing Address - Fax:360-736-6552
Practice Address - Street 1:1911 COOKS HILL RD
Practice Address - Street 2:
Practice Address - City:CENTRALIA
Practice Address - State:WA
Practice Address - Zip Code:98531-9073
Practice Address - Country:US
Practice Address - Phone:360-736-6778
Practice Address - Fax:360-736-6552
Is Sole Proprietor?:No
Enumeration Date:2012-01-11
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA1006104133VN1005X
WADI60220652133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2040828Medicaid