Provider Demographics
NPI:1093050247
Name:STAFFORD, ELIZABETH W (RD, LD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:W
Last Name:STAFFORD
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:ELIZABETH
Other - Middle Name:W
Other - Last Name:BASTIAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:410 W 10TH AVE
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43210-1240
Mailing Address - Country:US
Mailing Address - Phone:614-293-9579
Mailing Address - Fax:
Practice Address - Street 1:410 W 10TH AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1240
Practice Address - Country:US
Practice Address - Phone:614-293-9579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-29
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7101133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered