Healthcare Provider Details

I. General information

NPI: 1972859973
Provider Name (Legal Business Name): STEPHANIE DYAN TARVER LDN,RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2012
Last Update Date: 07/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1035 CRESWELL AVE
SHREVEPORT LA
71101-3917
US

IV. Provider business mailing address

1525 FAIRFIELD AVE RM. 569
SHREVEPORT LA
71101-4300
US

V. Phone/Fax

Practice location:
  • Phone: 318-676-5159
  • Fax:
Mailing address:
  • Phone: 318-676-7473
  • Fax: 318-676-7560

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number1313
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number832710
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: