Provider Demographics
NPI:1437482890
Name:ROBERTS-DAVIS, STACY CARLENE (RD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:CARLENE
Last Name:ROBERTS-DAVIS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5200 NE 3RD TERRACE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND PARK
Mailing Address - State:FL
Mailing Address - Zip Code:33334
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5200 NE 3RD TER
Practice Address - Street 2:
Practice Address - City:OAKLAND PARK
Practice Address - State:FL
Practice Address - Zip Code:33334-2404
Practice Address - Country:US
Practice Address - Phone:954-682-3526
Practice Address - Fax:954-533-1378
Is Sole Proprietor?:Yes
Enumeration Date:2009-09-16
Last Update Date:2015-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND4691133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered