Provider Demographics
NPI:1639620222
Name:MIND BODY NUTRITION RN
Entity Type:Organization
Organization Name:MIND BODY NUTRITION RN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:
Authorized Official - Last Name:VANCE-BEAUMONT
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:415-867-6457
Mailing Address - Street 1:75-5995 KUAKINI HWY STE 445
Mailing Address - Street 2:
Mailing Address - City:KAILUA KONA
Mailing Address - State:HI
Mailing Address - Zip Code:96740-2123
Mailing Address - Country:US
Mailing Address - Phone:808-315-8466
Mailing Address - Fax:
Practice Address - Street 1:75-5995 KUAKINI HWY STE 445
Practice Address - Street 2:
Practice Address - City:KAILUA KONA
Practice Address - State:HI
Practice Address - Zip Code:96740-2123
Practice Address - Country:US
Practice Address - Phone:808-315-8466
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-18
Last Update Date:2016-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI2154364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGroup - Single Specialty