Provider Demographics
NPI:1114466794
Name:POTVIN, REBECCA (RD, LD, CLC)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:POTVIN
Suffix:
Gender:F
Credentials:RD, LD, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:650 HUEBNER RD
Mailing Address - Street 2:
Mailing Address - City:FORT RILEY
Mailing Address - State:KS
Mailing Address - Zip Code:66442-4030
Mailing Address - Country:US
Mailing Address - Phone:785-239-7667
Mailing Address - Fax:
Practice Address - Street 1:650 HUEBNER RD
Practice Address - Street 2:
Practice Address - City:FORT RILEY
Practice Address - State:KS
Practice Address - Zip Code:66442-4030
Practice Address - Country:US
Practice Address - Phone:785-239-7667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-16
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1665133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered