Provider Demographics
NPI:1043889926
Name:CASUCCI, STACY NICOLE (RDN)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:NICOLE
Last Name:CASUCCI
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:827 GREVELIA ST APT A
Mailing Address - Street 2:
Mailing Address - City:SOUTH PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91030-2437
Mailing Address - Country:US
Mailing Address - Phone:323-837-8177
Mailing Address - Fax:
Practice Address - Street 1:420 E 3RD ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90013-1644
Practice Address - Country:US
Practice Address - Phone:213-625-0706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-23
Last Update Date:2022-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86037217133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered