Provider Demographics
NPI:1366976656
Name:WAN, DAISY Y (RD)
Entity type:Individual
Prefix:
First Name:DAISY
Middle Name:Y
Last Name:WAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2222
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:1750 112TH AVE NE
Practice Address - Street 2:BLDG 4 STE E175
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3752
Practice Address - Country:US
Practice Address - Phone:425-289-0381
Practice Address - Fax:425-289-0387
Is Sole Proprietor?:No
Enumeration Date:2017-04-13
Last Update Date:2017-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001207133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered