Provider Demographics
NPI:1730387986
Name:DOUGLAS, BROOKE S (RD)
Entity type:Individual
Prefix:MRS
First Name:BROOKE
Middle Name:S
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:BROOKE
Other - Middle Name:S
Other - Last Name:BEAVERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:15308 136TH AVE E
Mailing Address - Street 2:
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98374-9241
Mailing Address - Country:US
Mailing Address - Phone:253-227-8284
Mailing Address - Fax:
Practice Address - Street 1:15308 136TH AVE E
Practice Address - Street 2:
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98374-9241
Practice Address - Country:US
Practice Address - Phone:253-227-8284
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-10
Last Update Date:2007-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA706866133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered