Provider Demographics
NPI:1760219281
Name:WOLFGRAM, BETH LYNNE (RD)
Entity type:Individual
Prefix:
First Name:BETH
Middle Name:LYNNE
Last Name:WOLFGRAM
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 81064
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44181-0064
Mailing Address - Country:US
Mailing Address - Phone:206-895-4292
Mailing Address - Fax:833-973-4034
Practice Address - Street 1:655 E RIVER RD UNIT 201
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85704-5853
Practice Address - Country:US
Practice Address - Phone:206-895-4292
Practice Address - Fax:833-973-4034
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-18
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI613133V00000X, 133VN1501X
FLND9159133V00000X
NCL006601133V00000X
SC3168133V00000X
NH1261133V00000X
AZ133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports Dietetics