Provider Demographics
NPI:1083437867
Name:STEPHAN, BROOKE (RD)
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:STEPHAN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 MOUNTAINSIDE PKWY
Mailing Address - Street 2:
Mailing Address - City:ELLIJAY
Mailing Address - State:GA
Mailing Address - Zip Code:30536-8319
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:121 E 62ND ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-4256
Practice Address - Country:US
Practice Address - Phone:678-646-7771
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-01
Last Update Date:2024-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD007075133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered