Provider Demographics
NPI:1083322903
Name:BEACHAM, STEPHANIE L (MS RDN LD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:L
Last Name:BEACHAM
Suffix:
Gender:F
Credentials:MS RDN LD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:L
Other - Last Name:NYBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9823 N P ST
Mailing Address - Street 2:
Mailing Address - City:LA PORTE
Mailing Address - State:TX
Mailing Address - Zip Code:77571-9425
Mailing Address - Country:US
Mailing Address - Phone:270-875-5528
Mailing Address - Fax:
Practice Address - Street 1:9823 N P ST
Practice Address - Street 2:
Practice Address - City:LA PORTE
Practice Address - State:TX
Practice Address - Zip Code:77571-9425
Practice Address - Country:US
Practice Address - Phone:270-875-5528
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-11-09
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT86523133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered