Provider Demographics
NPI:1083860605
Name:ROY, STELLA M (MBA, RD)
Entity Type:Individual
Prefix:
First Name:STELLA
Middle Name:M
Last Name:ROY
Suffix:
Gender:F
Credentials:MBA, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1475 NW 12TH AVE
Mailing Address - Street 2:BOX 016960
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1002
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1475 NW 12TH AVE
Practice Address - Street 2:BOX 016960
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1002
Practice Address - Country:US
Practice Address - Phone:305-243-5180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-14
Last Update Date:2008-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ZZND1402133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU2584Medicare UPIN