Provider Demographics
NPI:1174063176
Name:HULTSTRAND, BETHANY (RDN)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:
Last Name:HULTSTRAND
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3234 N 38TH ST APT 15
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-6339
Mailing Address - Country:US
Mailing Address - Phone:612-644-0811
Mailing Address - Fax:
Practice Address - Street 1:220 S 12TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-3101
Practice Address - Country:US
Practice Address - Phone:602-372-2142
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-24
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86031850133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered