Provider Demographics
NPI:1376200741
Name:WEICHELT, STACEY M (RD, CD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:WEICHELT
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120431 ROCK RD
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:WI
Mailing Address - Zip Code:54484-4280
Mailing Address - Country:US
Mailing Address - Phone:715-506-0060
Mailing Address - Fax:
Practice Address - Street 1:120431 ROCK RD
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:WI
Practice Address - Zip Code:54484-4280
Practice Address - Country:US
Practice Address - Phone:715-506-0060
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-20
Last Update Date:2021-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI999381133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered