Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 12616 | TX |
NPI | 1194169524 |
---|---|
Provider Name | Stephanie Bahlman |
First Address | San Angelo, TX 76904-5983 |
Second Address | Irving, TX 75063-5219 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 29/04/2013 |
Last Update Date | 04/01/2019 |