=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932083961
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROUD PEACEFUL NUTRITION, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/04/2025
-----------------------------------------------------
Last Update Date | 08/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2751 OAKDALE BLVD STE 1
-----------------------------------------------------
City | CORALVILLE
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52241-9749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-331-9017
-----------------------------------------------------
Fax | 319-469-8763
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1720 SILVER MAPLE TRL
-----------------------------------------------------
City | NORTH LIBERTY
-----------------------------------------------------
State | IA
-----------------------------------------------------
Zip | 52317-4740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 319-331-9017
-----------------------------------------------------
Fax | 319-469-8763
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER, REGISTERED DIETITIAN
-----------------------------------------------------
Name | MRS. STEPHANIE L PROUD
-----------------------------------------------------
Credential | RDN, LD
-----------------------------------------------------
Telephone | 319-331-9017
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM0801X
-----------------------------------------------------
Taxonomy Name | Mental Health Clinic/Center (Including Community Mental Health Center)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------