Provider Demographics
NPI:1386407211
Name:STROM, DEIDRA (MS, RDN, LD)
Entity type:Individual
Prefix:
First Name:DEIDRA
Middle Name:
Last Name:STROM
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2608 HIGHWAY 9 S
Mailing Address - Street 2:
Mailing Address - City:PERRYVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72126-8128
Mailing Address - Country:US
Mailing Address - Phone:501-733-6560
Mailing Address - Fax:
Practice Address - Street 1:2608 HIGHWAY 9 S
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:AR
Practice Address - Zip Code:72126-8128
Practice Address - Country:US
Practice Address - Phone:501-733-6560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1677133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered