Provider Demographics
NPI:1053787937
Name:BEENKEN, STEPHANIE RAE (RDN, LD)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:RAE
Last Name:BEENKEN
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:203 ARDIS ST
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:IA
Mailing Address - Zip Code:50643-2016
Mailing Address - Country:US
Mailing Address - Phone:319-215-7620
Mailing Address - Fax:
Practice Address - Street 1:945 TOWER PARK DR
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-9098
Practice Address - Country:US
Practice Address - Phone:319-235-1230
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-14
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA001792133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered