Provider Demographics
NPI:1508126475
Name:COOLBAUGH, STACY A (RD)
Entity Type:Individual
Prefix:MS
First Name:STACY
Middle Name:A
Last Name:COOLBAUGH
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 1:1000 EAST MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18711
Mailing Address - Country:US
Mailing Address - Phone:570-214-5681
Mailing Address - Fax:
Practice Address - Street 1:100 N ACADEMY AVE
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:PA
Practice Address - Zip Code:17822-0115
Practice Address - Country:US
Practice Address - Phone:570-271-6468
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-24
Last Update Date:2018-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN001156133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered