Provider Demographics
NPI:1235654922
Name:BALA, STACEY (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BALA
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 1:911 WASHINGTON ST APT 103
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27605-3205
Mailing Address - Country:US
Mailing Address - Phone:845-264-1199
Mailing Address - Fax:
Practice Address - Street 1:911 WASHINGTON ST APT 103
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27605-3205
Practice Address - Country:US
Practice Address - Phone:845-264-1199
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-03
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004237133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered