Provider Demographics
NPI:1609834332
Name:PECHSTEIN, SALLY (RDN)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:PECHSTEIN
Suffix:
Gender:F
Credentials:RDN
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 2980
Mailing Address - Street 2:
Mailing Address - City:CORRALES
Mailing Address - State:NM
Mailing Address - Zip Code:87048-2980
Mailing Address - Country:US
Mailing Address - Phone:808-866-8142
Mailing Address - Fax:
Practice Address - Street 1:295 NOBLE LN
Practice Address - Street 2:
Practice Address - City:CORRALES
Practice Address - State:NM
Practice Address - Zip Code:87048-7703
Practice Address - Country:US
Practice Address - Phone:808-866-8142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT89872133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0172935OtherL&I PIN
WA9723PEOtherREGENCE BLUE SHIELD
WA8330169Medicaid
WA8330169Medicaid
WA8800028Medicare PIN