Provider Demographics
NPI:1033667704
Name:SUDJIAN, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SUDJIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 BYERS DR # 1072
Mailing Address - Street 2:
Mailing Address - City:GLEN MILLS
Mailing Address - State:PA
Mailing Address - Zip Code:19342-3323
Mailing Address - Country:US
Mailing Address - Phone:508-319-9537
Mailing Address - Fax:
Practice Address - Street 1:901 BYERS DR # 1072
Practice Address - Street 2:
Practice Address - City:GLEN MILLS
Practice Address - State:PA
Practice Address - Zip Code:19342-3323
Practice Address - Country:US
Practice Address - Phone:508-319-9537
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-12
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4137133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered