Healthcare Provider Details

I. General information

NPI: 1174063176
Provider Name (Legal Business Name): BETHANY HULTSTRAND RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 02/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 S 12TH AVE
PHOENIX AZ
85007-3101
US

IV. Provider business mailing address

3234 N 38TH ST APT 15
PHOENIX AZ
85018-6339
US

V. Phone/Fax

Practice location:
  • Phone: 602-372-2142
  • Fax:
Mailing address:
  • Phone: 612-644-0811
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86031850
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: