Provider Demographics
NPI:1477942399
Name:GERKEN, STACI (RD)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:GERKEN
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 1:3215 EAGLE CREST DR NE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49525-7005
Mailing Address - Country:US
Mailing Address - Phone:616-222-7007
Mailing Address - Fax:616-456-5692
Practice Address - Street 1:3215 EAGLE CREST DR NE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49525-7005
Practice Address - Country:US
Practice Address - Phone:616-222-7007
Practice Address - Fax:616-456-5692
Is Sole Proprietor?:No
Enumeration Date:2015-01-15
Last Update Date:2015-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered