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General NPI Number Information
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NPI Number | 1649717562
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Entity Type | Individual
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Provider Name | MADELINE BANTA RD, LD
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Gender | Female
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Dates
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Enumeration Date | 01/30/2017
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Last Update Date | 02/02/2022
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Provider Practice Location Address
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Address Line | 100 N MARIO CAPECCHI DR
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City | SALT LAKE CITY
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State | UT
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Zip | 84113-1103
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Country | US
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Telephone | 801-662-5329
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Fax |
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Provider Business Mailing Address
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Address Line | 865 S AMANDA AVE
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City | SALT LAKE CITY
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State | UT
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Zip | 84105-1625
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Country | US
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Telephone | 801-755-8056
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 133VN1004X
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Taxonomy Name | Pediatric Nutrition Registered Dietitian
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License Number |
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License Number State | ID
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