Provider Demographics
NPI:1104384890
Name:TAZI-SIDQUI, STEPHANIE
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:TAZI-SIDQUI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9740 SW 40TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33165-4080
Mailing Address - Country:US
Mailing Address - Phone:305-662-5200
Mailing Address - Fax:
Practice Address - Street 1:9740 SW 40TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33165-4080
Practice Address - Country:US
Practice Address - Phone:305-662-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-12
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4008133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist