Provider Demographics
NPI:1558685065
Name:WOODSON, STACEY (MS, RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:
Last Name:WOODSON
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:
Other - Last Name:MATTHEWS-WOODSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, RD, LDN
Mailing Address - Street 1:1424 KENILWORTH ST
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19146-2208
Mailing Address - Country:US
Mailing Address - Phone:267-239-5637
Mailing Address - Fax:
Practice Address - Street 1:3412 TYSON RD
Practice Address - Street 2:
Practice Address - City:NEWTOWN SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19073-3420
Practice Address - Country:US
Practice Address - Phone:610-359-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-26
Last Update Date:2018-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN003988133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered