Healthcare Provider Details

I. General information

NPI: 1316521370
Provider Name (Legal Business Name): SYMONE STEVIE RECTOR RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SYMONE STEVIE JACOBS

II. Dates (important events)

Enumeration Date: 05/06/2021
Last Update Date: 08/13/2024
Certification Date: 08/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 32ND AVE S
FARGO ND
58103-5800
US

IV. Provider business mailing address

PO BOX 5074
SIOUX FALLS SD
57117-5074
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-2000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1207
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number1207
License Number StateND
# 3
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number4431
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: