Provider Demographics
NPI:1487854410
Name:BUSEY, STACEY LYNN (RD, CD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:BUSEY
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 1:602 E NOB HILL BLVD
Mailing Address - Street 2:WIC PROGRAM
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98901-3534
Mailing Address - Country:US
Mailing Address - Phone:509-248-8602
Mailing Address - Fax:509-577-4686
Practice Address - Street 1:602 E NOB HILL BLVD
Practice Address - Street 2:WIC PROGRAM
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-3534
Practice Address - Country:US
Practice Address - Phone:509-248-8602
Practice Address - Fax:509-577-4686
Is Sole Proprietor?:No
Enumeration Date:2007-07-18
Last Update Date:2007-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001545133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8415663Medicaid