Provider Demographics
NPI:1376073346
Name:FANG, BETHAN (RD)
Entity Type:Individual
Prefix:
First Name:BETHAN
Middle Name:
Last Name:FANG
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:89 BIRCH ST
Mailing Address - Street 2:
Mailing Address - City:CLOSTER
Mailing Address - State:NJ
Mailing Address - Zip Code:07624-1702
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:89 BIRCH ST
Practice Address - Street 2:
Practice Address - City:CLOSTER
Practice Address - State:NJ
Practice Address - Zip Code:07624-1702
Practice Address - Country:US
Practice Address - Phone:516-456-1982
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-13
Last Update Date:2017-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist