Provider Demographics
NPI:1124220108
Name:STACEY, SUZANNE E (RD, LD)
Entity Type:Individual
Prefix:
First Name:SUZANNE
Middle Name:E
Last Name:STACEY
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3629 MCCLOUD ST
Mailing Address - Street 2:
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34655-2609
Mailing Address - Country:US
Mailing Address - Phone:727-834-8199
Mailing Address - Fax:
Practice Address - Street 1:2040 SHORT AVE
Practice Address - Street 2:SUITE 100
Practice Address - City:ODESSA
Practice Address - State:FL
Practice Address - Zip Code:33556-3445
Practice Address - Country:US
Practice Address - Phone:727-372-9922
Practice Address - Fax:727-372-8477
Is Sole Proprietor?:No
Enumeration Date:2007-06-03
Last Update Date:2010-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4959133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered