Provider Demographics
NPI:1235327453
Name:CLINTON, STACIA ANNE (RD)
Entity Type:Individual
Prefix:MS
First Name:STACIA
Middle Name:ANNE
Last Name:CLINTON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 ALFRED DR
Mailing Address - Street 2:
Mailing Address - City:TOLLAND
Mailing Address - State:CT
Mailing Address - Zip Code:06084-3140
Mailing Address - Country:US
Mailing Address - Phone:860-798-8645
Mailing Address - Fax:
Practice Address - Street 1:500 FRANKLIN VILLAGE DR
Practice Address - Street 2:SUITE 106
Practice Address - City:FRANKLIN
Practice Address - State:MA
Practice Address - Zip Code:02038-4017
Practice Address - Country:US
Practice Address - Phone:860-798-8645
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-12
Last Update Date:2007-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MANU 2590133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered