Healthcare Provider Details

I. General information

NPI: 1124603790
Provider Name (Legal Business Name): AUDREY NICOLE HESTER RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AUDREY NICOLE REEVES

II. Dates (important events)

Enumeration Date: 03/15/2021
Last Update Date: 03/15/2021
Certification Date: 03/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 NE PROFESSIONAL CT
BEND OR
97701-6063
US

IV. Provider business mailing address

1135 KALMIA ST
JUNCTION CITY OR
97448-1951
US

V. Phone/Fax

Practice location:
  • Phone: 541-389-6313
  • Fax: 541-389-8760
Mailing address:
  • Phone: 541-678-1626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-D-10204853
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: