Provider Demographics
NPI:1265629422
Name:STEGEMANN, SALLY JANE (RD)
Entity Type:Individual
Prefix:MRS
First Name:SALLY
Middle Name:JANE
Last Name:STEGEMANN
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:JANE
Other - Last Name:KELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1508 KILLIAN CT
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65203-5106
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3610 BUTTONWOOD DR
Practice Address - Street 2:SUITE 200
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65201-3721
Practice Address - Country:US
Practice Address - Phone:573-489-7997
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-01
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005039286133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered