Provider Demographics
NPI:1730954983
Name:MAYFIELD, ROSALINE PATRICIA
Entity type:Individual
Prefix:
First Name:ROSALINE
Middle Name:PATRICIA
Last Name:MAYFIELD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4012 S 15TH ST
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD
Mailing Address - State:WA
Mailing Address - Zip Code:98642-8389
Mailing Address - Country:US
Mailing Address - Phone:360-980-1869
Mailing Address - Fax:
Practice Address - Street 1:4012 S 15TH ST
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD
Practice Address - State:WA
Practice Address - Zip Code:98642-8389
Practice Address - Country:US
Practice Address - Phone:360-980-1869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-17
Last Update Date:2023-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI61498617133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered