Provider Demographics
NPI:1417398454
Name:BULLAT, AMANDA KAY (RD)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:KAY
Last Name:BULLAT
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 1:18495 BALLINGER WAY NE
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST PARK
Mailing Address - State:WA
Mailing Address - Zip Code:98155-4238
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:18495 BALLINGER WAY NE
Practice Address - Street 2:
Practice Address - City:LAKE FOREST PARK
Practice Address - State:WA
Practice Address - Zip Code:98155-4238
Practice Address - Country:US
Practice Address - Phone:541-647-9185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-06
Last Update Date:2013-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI 60133367133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered