Provider Demographics
NPI:1659816304
Name:BANKHEAD, REBECKA ANDERSON (RD, CD)
Entity Type:Individual
Prefix:
First Name:REBECKA
Middle Name:ANDERSON
Last Name:BANKHEAD
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:PO BOX 154
Mailing Address - Street 2:
Mailing Address - City:PARADISE
Mailing Address - State:UT
Mailing Address - Zip Code:84328-0154
Mailing Address - Country:US
Mailing Address - Phone:435-760-2538
Mailing Address - Fax:
Practice Address - Street 1:8790 SOUTH 300 WEST
Practice Address - Street 2:
Practice Address - City:PARADISE
Practice Address - State:UT
Practice Address - Zip Code:84328-0154
Practice Address - Country:US
Practice Address - Phone:435-760-2538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-04
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9040610-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered