Provider Demographics
NPI:1972859973
Name:TARVER, STEPHANIE DYAN (LDN,RD)
Entity type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:DYAN
Last Name:TARVER
Suffix:
Gender:F
Credentials:LDN,RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 FAIRFIELD AVE
Mailing Address - Street 2:RM. 569
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4300
Mailing Address - Country:US
Mailing Address - Phone:318-676-7473
Mailing Address - Fax:318-676-7560
Practice Address - Street 1:1035 CRESWELL AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-3917
Practice Address - Country:US
Practice Address - Phone:318-676-5159
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-27
Last Update Date:2012-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1313133NN1002X
LA832710133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education