Healthcare Provider Details

I. General information

NPI: 1154886018
Provider Name (Legal Business Name): STEPHANIE B KOBETZ RDN, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/05/2019
Last Update Date: 02/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 BRANCH CIR
LAFAYETTE LA
70508-6323
US

IV. Provider business mailing address

105 BRANCH CIR
LAFAYETTE LA
70508-6323
US

V. Phone/Fax

Practice location:
  • Phone: 337-501-5474
  • Fax:
Mailing address:
  • Phone: 337-501-5474
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2900
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: