Healthcare Provider Details

I. General information

NPI: 1952573453
Provider Name (Legal Business Name): TRUDY BERNICE EKSTROM CN, MS, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2008
Last Update Date: 03/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2620 REGATTA DR SUITE 102
LAS VEGAS NV
89128-6891
US

IV. Provider business mailing address

2620 REGATTA DR SUITE 102
LAS VEGAS NV
89128-6891
US

V. Phone/Fax

Practice location:
  • Phone: 702-363-9260
  • Fax: 702-658-6721
Mailing address:
  • Phone: 702-363-9260
  • Fax: 702-658-6721

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberH11-00044-C-096986
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: