Provider Demographics
NPI:1508227042
Name:STEPHENS, RACHEL (RD, CD)
Entity Type:Individual
Prefix:MRS
First Name:RACHEL
Middle Name:
Last Name:STEPHENS
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11726 PAINTED PEAK WAY
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-2068
Mailing Address - Country:US
Mailing Address - Phone:260-338-0872
Mailing Address - Fax:
Practice Address - Street 1:2520 E DUPONT RD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46825-1675
Practice Address - Country:US
Practice Address - Phone:260-416-3263
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-11
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37001460A133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered