Provider Demographics
NPI:1811310360
Name:BEESON, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:BEESON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 PROMENADE DR
Mailing Address - Street 2:
Mailing Address - City:SUPERIOR
Mailing Address - State:CO
Mailing Address - Zip Code:80027-8652
Mailing Address - Country:US
Mailing Address - Phone:208-559-0307
Mailing Address - Fax:
Practice Address - Street 1:102 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-6124
Practice Address - Country:US
Practice Address - Phone:208-381-7831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-02-03
Last Update Date:2021-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO810997133V00000X
IDD-360133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered