Provider Demographics
NPI:1366651846
Name:CASTLE, STACIE K (RD)
Entity Type:Individual
Prefix:MS
First Name:STACIE
Middle Name:K
Last Name:CASTLE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:62 FORSYTHIA LANE
Mailing Address - Street 2:
Mailing Address - City:JERICHO
Mailing Address - State:NY
Mailing Address - Zip Code:11753
Mailing Address - Country:US
Mailing Address - Phone:516-652-2747
Mailing Address - Fax:516-935-2058
Practice Address - Street 1:2001 MARCUS AVE
Practice Address - Street 2:SUITE N220
Practice Address - City:LAKE SUCCESS
Practice Address - State:NY
Practice Address - Zip Code:11042
Practice Address - Country:US
Practice Address - Phone:516-652-2747
Practice Address - Fax:516-935-2058
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0023311133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP2576072OtherOXFORD
NYP2035293003OtherUNITED HEALTHCARE
NY9014E1OtherEMPIRE BLUE CROSS BLUE SHIELD
NYP2576072OtherOXFORD