Provider Demographics
NPI:1447349469
Name:HEESACKER, JUDITH DARLENE (MS, RD, CD)
Entity type:Individual
Prefix:
First Name:JUDITH
Middle Name:DARLENE
Last Name:HEESACKER
Suffix:
Gender:F
Credentials:MS, RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:518 N PINE ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-3196
Mailing Address - Country:US
Mailing Address - Phone:509-933-2838
Mailing Address - Fax:
Practice Address - Street 1:518 N PINE ST
Practice Address - Street 2:SUITE 102
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-3196
Practice Address - Country:US
Practice Address - Phone:509-933-2838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001032133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
816310OtherCDR
WADI00001032OtherSTATE LICENSE CD
WAAB29206Medicare ID - Type UnspecifiedMEDICARE PROVIDER #