Provider Demographics
NPI:1174821425
Name:DEQUINA, STACY RENEE (RD, CDE)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:RENEE
Last Name:DEQUINA
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20361 CLARK ST
Mailing Address - Street 2:
Mailing Address - City:WOODLAND HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91367-5508
Mailing Address - Country:US
Mailing Address - Phone:818-642-1494
Mailing Address - Fax:
Practice Address - Street 1:20361 CLARK ST
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-5508
Practice Address - Country:US
Practice Address - Phone:818-642-1494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA859099133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered