Personal Information

This section collects your basic demographic details, like your full legal name, Type 1 NPI, and date of birth. It also includes your practice states.

Additional states may need to be added as we credential you. Adding a new state can trigger required questions and documents within your CAQH profile.

📸 Make sure these fields are completed exactly as shown to avoid credentialing issues:

• NUCC Grouping: Dietary & Nutrition Service Providers

• Provider Type: Dietitian

• Practice Setting: Inpatient/Outpatient or Outpatient Only

• Practice State: Oregon (or the state(s) where you’re licensed)