Provider Demographics
NPI:1790820207
Name:DEBROWER, TRESA L (RD,LD)
Entity Type:Individual
Prefix:MS
First Name:TRESA
Middle Name:L
Last Name:DEBROWER
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1710 K AVE NE
Mailing Address - Street 2:
Mailing Address - City:CEDAR RAPIDS
Mailing Address - State:IA
Mailing Address - Zip Code:52402-4707
Mailing Address - Country:US
Mailing Address - Phone:319-364-6137
Mailing Address - Fax:
Practice Address - Street 1:701 10TH ST SE
Practice Address - Street 2:
Practice Address - City:CEDAR RAPIDS
Practice Address - State:IA
Practice Address - Zip Code:52403-1251
Practice Address - Country:US
Practice Address - Phone:319-398-6711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA00884133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA110200Medicare ID - Type UnspecifiedMEDICAL NUTRITION THERAPY