Provider Demographics
NPI:1366439028
Name:PROUD, STEPHANIE L (RDN LD CNSC)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:L
Last Name:PROUD
Suffix:
Gender:F
Credentials:RDN LD CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-467-2842
Mailing Address - Fax:319-356-8674
Practice Address - Street 1:2140 NORCOR AVE STE 104
Practice Address - Street 2:
Practice Address - City:CORALVILLE
Practice Address - State:IA
Practice Address - Zip Code:52241-9736
Practice Address - Country:US
Practice Address - Phone:319-331-9017
Practice Address - Fax:319-469-8763
Is Sole Proprietor?:No
Enumeration Date:2005-09-28
Last Update Date:2025-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01596133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAI11344Medicare PIN
Q08946Medicare UPIN