Provider Demographics
NPI:1427189075
Name:ROTH, STACY ANNE (RD, LDN, MPH)
Entity Type:Individual
Prefix:MISS
First Name:STACY
Middle Name:ANNE
Last Name:ROTH
Suffix:
Gender:F
Credentials:RD, LDN, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9039 W CHURCH ST
Mailing Address - Street 2:APT 1H
Mailing Address - City:DES PLAINES
Mailing Address - State:IL
Mailing Address - Zip Code:60016-7008
Mailing Address - Country:US
Mailing Address - Phone:630-201-3847
Mailing Address - Fax:
Practice Address - Street 1:9039 W CHURCH ST
Practice Address - Street 2:APT 1H
Practice Address - City:DES PLAINES
Practice Address - State:IL
Practice Address - Zip Code:60016-7008
Practice Address - Country:US
Practice Address - Phone:630-201-3847
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered