Provider Demographics
NPI:1174776991
Name:ABBOTT, KORI FAWN (RD)
Entity type:Individual
Prefix:MS
First Name:KORI
Middle Name:FAWN
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MS
Other - First Name:KORI
Other - Middle Name:FAWN
Other - Last Name:CLOT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:655 AL DORSEY LN NW
Mailing Address - Street 2:
Mailing Address - City:BAINBRIDGE ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98110-2729
Mailing Address - Country:US
Mailing Address - Phone:206-201-3642
Mailing Address - Fax:
Practice Address - Street 1:655 AL DORSEY LN NW
Practice Address - Street 2:
Practice Address - City:BAINBRIDGE ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98110-2729
Practice Address - Country:US
Practice Address - Phone:206-201-3642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-10-23
Last Update Date:2008-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI 60023537133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered