Provider Demographics
NPI:1063702389
Name:BENDA, BEVERLY M (RDN)
Entity type:Individual
Prefix:
First Name:BEVERLY
Middle Name:M
Last Name:BENDA
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 1:1114 S 19TH ST
Mailing Address - Street 2:
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58201-5122
Mailing Address - Country:US
Mailing Address - Phone:701-610-9529
Mailing Address - Fax:
Practice Address - Street 1:1114 S 19TH ST
Practice Address - Street 2:
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58201-5122
Practice Address - Country:US
Practice Address - Phone:701-610-9529
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-08
Last Update Date:2016-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND211133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered