Provider Demographics
NPI:1174098024
Name:FELTUS, STEPHANIE ANN (RDN, LMNT, LD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:ANN
Last Name:FELTUS
Suffix:
Gender:F
Credentials:RDN, LMNT, LD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:ANN
Other - Last Name:MINOR, MULLY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:16123 SPRING ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2031
Mailing Address - Country:US
Mailing Address - Phone:402-312-0124
Mailing Address - Fax:
Practice Address - Street 1:4611 S 96TH ST STE 237
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68127-1243
Practice Address - Country:US
Practice Address - Phone:402-312-0124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE634133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA01484OtherLICENSED DIETITIAN
NE634OtherMEDICAL NUTRITION THERAPY