Provider Demographics
NPI:1700391091
Name:BEVAN, STACY LYN (RD)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:LYN
Last Name:BEVAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:478 S 750 E
Mailing Address - Street 2:
Mailing Address - City:RIVER HEIGHTS
Mailing Address - State:UT
Mailing Address - Zip Code:84321-4490
Mailing Address - Country:US
Mailing Address - Phone:435-764-4907
Mailing Address - Fax:
Practice Address - Street 1:478 S 750 E
Practice Address - Street 2:
Practice Address - City:RIVER HEIGHTS
Practice Address - State:UT
Practice Address - Zip Code:84321-4490
Practice Address - Country:US
Practice Address - Phone:435-764-4907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-08
Last Update Date:2017-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered