Provider Demographics
NPI:1124570411
Name:FOSS, STEPHANIE (MS,RD,LDN,CDE)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:FOSS
Suffix:
Gender:F
Credentials:MS,RD,LDN,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1699 SW 16TH AVE
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32608-1158
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1699 SW 16TH AVE
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:FL
Practice Address - Zip Code:32608-1158
Practice Address - Country:US
Practice Address - Phone:352-265-7337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-02
Last Update Date:2016-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND7685133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered