Provider Demographics
NPI:1154313427
Name:VETROVSKY, STACI MICHELLE (RD, LDN)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:MICHELLE
Last Name:VETROVSKY
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 S HIGHLAND AVE
Mailing Address - Street 2:APT 364
Mailing Address - City:LOMBARD
Mailing Address - State:IL
Mailing Address - Zip Code:60148-5302
Mailing Address - Country:US
Mailing Address - Phone:847-420-2042
Mailing Address - Fax:
Practice Address - Street 1:353 E BURLINGTON ST
Practice Address - Street 2:SUITE 202
Practice Address - City:RIVERSIDE
Practice Address - State:IL
Practice Address - Zip Code:60546-2189
Practice Address - Country:US
Practice Address - Phone:708-442-6006
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered