Provider Demographics
NPI:1043246945
Name:SANDALL, MARY JANE (RD, CD)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:JANE
Last Name:SANDALL
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2200
Mailing Address - Street 2:26 WEST H STREET, STE B
Mailing Address - City:DEER PARK
Mailing Address - State:WA
Mailing Address - Zip Code:99006-2200
Mailing Address - Country:US
Mailing Address - Phone:509-276-7522
Mailing Address - Fax:509-276-7522
Practice Address - Street 1:26 WEST H STREET
Practice Address - Street 2:SUITE B
Practice Address - City:DEER PARK
Practice Address - State:WA
Practice Address - Zip Code:99006-2200
Practice Address - Country:US
Practice Address - Phone:509-276-7522
Practice Address - Fax:509-276-7522
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-23
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000785133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7601149Medicaid
WA7601149Medicaid
WAP89253Medicare UPIN