Provider Demographics
NPI:1083653471
Name:STANSELL, MARY K (RD LD CDE)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:K
Last Name:STANSELL
Suffix:
Gender:F
Credentials:RD LD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 STEWART AVENUE
Mailing Address - Street 2:SUITE #101
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-3609
Mailing Address - Country:US
Mailing Address - Phone:541-776-2003
Mailing Address - Fax:541-776-9833
Practice Address - Street 1:221 STEWART AVENUE
Practice Address - Street 2:SUITE #101
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-3609
Practice Address - Country:US
Practice Address - Phone:541-776-2003
Practice Address - Fax:541-776-9833
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR136133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P54344Medicare UPIN
115835Medicare ID - Type Unspecified