Provider Demographics
NPI:1407185010
Name:PACKRALL, STEPHANIE LAUREN (RD, LD, CLC)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LAUREN
Last Name:PACKRALL
Suffix:
Gender:F
Credentials:RD, LD, CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5640 MAIN ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:NEW PORT RICHEY
Mailing Address - State:FL
Mailing Address - Zip Code:34652-2637
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5640 MAIN ST
Practice Address - Street 2:SUITE 100
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-2637
Practice Address - Country:US
Practice Address - Phone:727-841-4425
Practice Address - Fax:727-841-4222
Is Sole Proprietor?:No
Enumeration Date:2009-12-10
Last Update Date:2009-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND 5655133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered