Provider Demographics
NPI:1164777652
Name:PROSTINE, BECKY ANN (MPH, RDLD)
Entity Type:Individual
Prefix:
First Name:BECKY
Middle Name:ANN
Last Name:PROSTINE
Suffix:
Gender:F
Credentials:MPH, RDLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17394 PACKARD AVE
Mailing Address - Street 2:
Mailing Address - City:CLARKSVILLE
Mailing Address - State:IA
Mailing Address - Zip Code:50619-9112
Mailing Address - Country:US
Mailing Address - Phone:319-278-4781
Mailing Address - Fax:
Practice Address - Street 1:800 11TH ST
Practice Address - Street 2:
Practice Address - City:CHARLES CITY
Practice Address - State:IA
Practice Address - Zip Code:50616-3468
Practice Address - Country:US
Practice Address - Phone:641-257-4381
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-20
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01748133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered