Provider Demographics
NPI:1346961125
Name:STACKHOUSE, LOGAN
Entity Type:Individual
Prefix:
First Name:LOGAN
Middle Name:
Last Name:STACKHOUSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2325 210TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT AYR
Mailing Address - State:IA
Mailing Address - Zip Code:50854-8891
Mailing Address - Country:US
Mailing Address - Phone:386-507-5449
Mailing Address - Fax:
Practice Address - Street 1:2325 210TH ST
Practice Address - Street 2:
Practice Address - City:MOUNT AYR
Practice Address - State:IA
Practice Address - Zip Code:50854-8891
Practice Address - Country:US
Practice Address - Phone:386-507-5449
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-08
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND8320133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered