Provider Demographics
NPI:1831703057
Name:BECKER, HYDEE FLISHAW TUBBS (RDN)
Entity type:Individual
Prefix:MRS
First Name:HYDEE
Middle Name:FLISHAW TUBBS
Last Name:BECKER
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:HYDEE
Other - Middle Name:FLISHAW
Other - Last Name:TUBBS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:614 NORTH HAYES STREET
Mailing Address - Street 2:
Mailing Address - City:MOSCOW
Mailing Address - State:ID
Mailing Address - Zip Code:83843
Mailing Address - Country:US
Mailing Address - Phone:952-607-5050
Mailing Address - Fax:
Practice Address - Street 1:614 NORTH HAYES STREET
Practice Address - Street 2:
Practice Address - City:MOSCOW
Practice Address - State:ID
Practice Address - Zip Code:83843
Practice Address - Country:US
Practice Address - Phone:952-607-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-880133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered