Provider Demographics
NPI:1730581711
Name:MONGILLO, LIV (MS, RDN, CD)
Entity type:Individual
Prefix:MRS
First Name:LIV
Middle Name:
Last Name:MONGILLO
Suffix:
Gender:F
Credentials:MS, RDN, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2170
Mailing Address - Street 2:
Mailing Address - City:SUMNER
Mailing Address - State:WA
Mailing Address - Zip Code:98390-0480
Mailing Address - Country:US
Mailing Address - Phone:253-840-2313
Mailing Address - Fax:253-840-6340
Practice Address - Street 1:25012 104TH AVE SE
Practice Address - Street 2:SUITE C
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98030-2821
Practice Address - Country:US
Practice Address - Phone:253-856-3477
Practice Address - Fax:253-856-3478
Is Sole Proprietor?:No
Enumeration Date:2014-09-21
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60436312133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered