Provider Demographics
NPI:1801551106
Name:SIM, MAGDA NICOLE (RD)
Entity type:Individual
Prefix:
First Name:MAGDA
Middle Name:NICOLE
Last Name:SIM
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:MAGDA
Other - Middle Name:NICOLE
Other - Last Name:OGOREK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1241 121ST AVE NE APT A101
Mailing Address - Street 2:
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98005-5025
Mailing Address - Country:US
Mailing Address - Phone:914-282-8031
Mailing Address - Fax:
Practice Address - Street 1:4455 148TH AVE NE
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-3120
Practice Address - Country:US
Practice Address - Phone:425-861-6255
Practice Address - Fax:425-861-6245
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-02
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA86150059133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WADI61228154OtherDEPARTMENT OF HEALTH