Provider Demographics
NPI:1255610051
Name:BEARDEN, MOLLY W (RD LD CDE)
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:W
Last Name:BEARDEN
Suffix:
Gender:F
Credentials:RD LD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1397 WEIMER RD
Mailing Address - Street 2:HOLY CROSS HOSPITAL
Mailing Address - City:TAOS
Mailing Address - State:NM
Mailing Address - Zip Code:87571-6253
Mailing Address - Country:US
Mailing Address - Phone:575-737-3290
Mailing Address - Fax:575-737-3286
Practice Address - Street 1:1397 WEIMER RD
Practice Address - Street 2:HOLY CROSS HOSPITAL
Practice Address - City:TAOS
Practice Address - State:NM
Practice Address - Zip Code:87571-6253
Practice Address - Country:US
Practice Address - Phone:575-737-3290
Practice Address - Fax:575-737-3286
Is Sole Proprietor?:No
Enumeration Date:2011-08-10
Last Update Date:2011-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM359133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered