Healthcare Provider Details

I. General information

NPI: 1679041511
Provider Name (Legal Business Name): BETHANI LEE MS, RDN, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2018
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 ELIZABETH ST
CORPUS CHRISTI TX
78404-2235
US

IV. Provider business mailing address

2202 NODDING PINES DR APT 236
CORPUS CHRISTI TX
78414-2482
US

V. Phone/Fax

Practice location:
  • Phone: 361-881-3000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDT84959
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License NumberDT84959
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License NumberDT84959
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberDT84959
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberDT84959
License Number StateTX
# 6
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT84959
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: