Provider Demographics
NPI:1689276800
Name:DEAN, REBEKAH JAYNE (RDN)
Entity Type:Individual
Prefix:
First Name:REBEKAH
Middle Name:JAYNE
Last Name:DEAN
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 JUPITER CT
Mailing Address - Street 2:
Mailing Address - City:INDIALANTIC
Mailing Address - State:FL
Mailing Address - Zip Code:32903-2103
Mailing Address - Country:US
Mailing Address - Phone:408-410-8275
Mailing Address - Fax:
Practice Address - Street 1:116 JUPITER CT
Practice Address - Street 2:
Practice Address - City:INDIALANTIC
Practice Address - State:FL
Practice Address - Zip Code:32903-2103
Practice Address - Country:US
Practice Address - Phone:408-410-8275
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-12
Last Update Date:2020-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86115281133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86115281OtherCOMMISSION ON DIETETIC REGISTRATION
FL9321OtherFLORIDA STATE DIETITIAN/NUTRITIONIST LICENSE