Provider Demographics
NPI:1275917882
Name:ELLIS, STACIE VANESSA (RDN, LD)
Entity Type:Individual
Prefix:DR
First Name:STACIE
Middle Name:VANESSA
Last Name:ELLIS
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:DR
Other - First Name:STACIE
Other - Middle Name:VANESSA
Other - Last Name:JONES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1200 SULLIVAN DR
Mailing Address - Street 2:
Mailing Address - City:CEDAR HILL
Mailing Address - State:TX
Mailing Address - Zip Code:75104-7340
Mailing Address - Country:US
Mailing Address - Phone:254-449-3952
Mailing Address - Fax:
Practice Address - Street 1:1200 SULLIVAN DR
Practice Address - Street 2:
Practice Address - City:CEDAR HILL
Practice Address - State:TX
Practice Address - Zip Code:75104-7340
Practice Address - Country:US
Practice Address - Phone:254-449-3952
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-13
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT83743133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist