Provider Demographics
NPI:1568051845
Name:SYNHORST, STEPHANIE PAIGE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:PAIGE
Last Name:SYNHORST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 W D. L. INGRAM AVENUE
Mailing Address - Street 2:
Mailing Address - City:CANNON AIR FORCE BASE
Mailing Address - State:NM
Mailing Address - Zip Code:88103
Mailing Address - Country:US
Mailing Address - Phone:402-310-2933
Mailing Address - Fax:
Practice Address - Street 1:224 W D. L. INGRAM AVENUE
Practice Address - Street 2:
Practice Address - City:CANNON AIR FORCE BASE
Practice Address - State:NM
Practice Address - Zip Code:88103
Practice Address - Country:US
Practice Address - Phone:402-310-2933
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1311133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered