Provider Demographics
NPI:1497416093
Name:BUCANNON, JULIE ANN CORPUZ (RD, LRD)
Entity Type:Individual
Prefix:MRS
First Name:JULIE ANN
Middle Name:CORPUZ
Last Name:BUCANNON
Suffix:
Gender:F
Credentials:RD, LRD
Other - Prefix:MS
Other - First Name:JULIE ANN
Other - Middle Name:QUEZON
Other - Last Name:CORPUZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RND
Mailing Address - Street 1:PO BOX 6002
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58206-6002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1200 S COLUMBIA RD
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-4044
Practice Address - Country:US
Practice Address - Phone:701-780-4045
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-05
Last Update Date:2024-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND1533133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1533OtherLICENSE REGISTERED DIETITIAN