Provider Demographics
NPI:1164816708
Name:O'CONNOR, STEFANIE ANNE (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:ANNE
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 TYNDALE ST
Mailing Address - Street 2:
Mailing Address - City:ROSLINDALE
Mailing Address - State:MA
Mailing Address - Zip Code:02131-2318
Mailing Address - Country:US
Mailing Address - Phone:617-699-1988
Mailing Address - Fax:
Practice Address - Street 1:129 TYNDALE ST
Practice Address - Street 2:
Practice Address - City:ROSLINDALE
Practice Address - State:MA
Practice Address - Zip Code:02131-2318
Practice Address - Country:US
Practice Address - Phone:617-699-1988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-21
Last Update Date:2015-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3375133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered