Provider Demographics
NPI:1356618011
Name:DISTER, REBECCA JANE (RD, LD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:JANE
Last Name:DISTER
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 1:13273 SPRUCE RUN DR APT 311
Mailing Address - Street 2:
Mailing Address - City:NORTH ROYALTON
Mailing Address - State:OH
Mailing Address - Zip Code:44133-4284
Mailing Address - Country:US
Mailing Address - Phone:440-227-4775
Mailing Address - Fax:
Practice Address - Street 1:13273 SPRUCE RUN DR APT 311
Practice Address - Street 2:
Practice Address - City:NORTH ROYALTON
Practice Address - State:OH
Practice Address - Zip Code:44133-4284
Practice Address - Country:US
Practice Address - Phone:440-227-4775
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-23
Last Update Date:2011-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1014155133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered