=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366659252
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BETH FAHNHORST N.P., R.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/17/2007
-----------------------------------------------------
Last Update Date | 01/03/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4150 CLEMENT ST
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94121-1563
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-551-7376
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 74 OUTLOOK CIR
-----------------------------------------------------
City | PACIFICA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94044-2145
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 650-355-9580
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 584739
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 606678
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------