Provider Demographics
NPI:1780214809
Name:KETCHUM, MARY (RDN, CD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:KETCHUM
Suffix:
Gender:F
Credentials:RDN, CD
Other - Prefix:
Other - First Name:MOLLY
Other - Middle Name:
Other - Last Name:MALLETTE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:700 LILLY RD NE
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98506-5115
Mailing Address - Country:US
Mailing Address - Phone:360-923-7000
Mailing Address - Fax:
Practice Address - Street 1:700 LILLY RD NE
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98506-5115
Practice Address - Country:US
Practice Address - Phone:360-923-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60878346133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered