Provider Demographics
NPI:1366996167
Name:BOSSE, SOPHIA (RD, CD)
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:BOSSE
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:SOPHIA
Other - Middle Name:
Other - Last Name:FONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, CD
Mailing Address - Street 1:11703 E SPRAGUE AVE STE C3
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99206-6129
Mailing Address - Country:US
Mailing Address - Phone:509-921-6560
Mailing Address - Fax:
Practice Address - Street 1:11703 E SPRAGUE AVE
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-6128
Practice Address - Country:US
Practice Address - Phone:509-921-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-09
Last Update Date:2016-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60515915133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered