Provider Demographics
NPI:1558790675
Name:STAUBLE, TAYLOR (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:STAUBLE
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1525 W HOMER ST
Mailing Address - Street 2:STE 101
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60642-1280
Mailing Address - Country:US
Mailing Address - Phone:773-292-1940
Mailing Address - Fax:
Practice Address - Street 1:8614 OLD BATES RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40228-2504
Practice Address - Country:US
Practice Address - Phone:502-310-9894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-08
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2585133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered