Provider Demographics
NPI:1114406485
Name:MCDORMAN, REBECCA (MS, RDN)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:MCDORMAN
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:BEC
Other - Middle Name:
Other - Last Name:MCDORMAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, RDN
Mailing Address - Street 1:39000 BOB HOPE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3221
Mailing Address - Country:US
Mailing Address - Phone:760-837-8041
Mailing Address - Fax:
Practice Address - Street 1:39000 BOB HOPE DR
Practice Address - Street 2:
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3221
Practice Address - Country:US
Practice Address - Phone:760-837-8041
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-08
Last Update Date:2020-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86055199133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86055199OtherCOMMISSION ON DIETETIC REGISTRATION
WADI60791542OtherWASHINGTON STATE DEPARTMENT OF HEALTH