Provider Demographics
NPI:1144835513
Name:TAIT, BETHANY H (MS, RDN)
Entity type:Individual
Prefix:
First Name:BETHANY
Middle Name:H
Last Name:TAIT
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:482 S 810 W APT 107
Mailing Address - Street 2:
Mailing Address - City:PLEASANT GROVE
Mailing Address - State:UT
Mailing Address - Zip Code:84062-2378
Mailing Address - Country:US
Mailing Address - Phone:772-403-3392
Mailing Address - Fax:
Practice Address - Street 1:482 S 810 W APT 107
Practice Address - Street 2:
Practice Address - City:PLEASANT GROVE
Practice Address - State:UT
Practice Address - Zip Code:84062-2378
Practice Address - Country:US
Practice Address - Phone:772-403-3392
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-13
Last Update Date:2020-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86056649133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered