MEDICARE: MRS. STEPHANIE L PROUD RDN LD CNSC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	01596	IA

General Provider Information

NPI Number	:	1366439028
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. STEPHANIE L PROUD RDN LD CNSC

Provider Business Mailing Address
First Line	:	200 HAWKINS DR
Second Line	:
City	:	IOWA CITY
State	:	IA
Zip	:	52242-1009
Country	:	US
Telephone Number	:	319-467-2842
Fax Number	:	319-356-8674

Provider Business Practice Location Address
First Line	:	2140 NORCOR AVE STE 104
Second Line	:
City	:	CORALVILLE
State	:	IA
Zip	:	52241-9736
Country	:	US
Telephone Number	:	319-331-9017
Fax Number	:	319-469-8763

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/28/2005
Last Update Date	:	08/03/2025

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