Provider Demographics
NPI:1093578148
Name:PURCELL, STACIA R (RD, LD, CDCES)
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:R
Last Name:PURCELL
Suffix:
Gender:F
Credentials:RD, LD, CDCES
Other - Prefix:
Other - First Name:STACIA
Other - Middle Name:R
Other - Last Name:PICKARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD, CDE
Mailing Address - Street 1:5300 DON MANUEL RD
Mailing Address - Street 2:
Mailing Address - City:ELKTON
Mailing Address - State:FL
Mailing Address - Zip Code:32033-3222
Mailing Address - Country:US
Mailing Address - Phone:904-662-2887
Mailing Address - Fax:
Practice Address - Street 1:5300 DON MANUEL RD
Practice Address - Street 2:
Practice Address - City:ELKTON
Practice Address - State:FL
Practice Address - Zip Code:32033-3222
Practice Address - Country:US
Practice Address - Phone:904-662-2887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-01
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND2080133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered