Provider Demographics
NPI:1598708570
Name:RYLANCE, STACIE MICHELE (RD)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:MICHELE
Last Name:RYLANCE
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:BOX 159
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-0159
Mailing Address - Country:US
Mailing Address - Phone:248-431-1521
Mailing Address - Fax:616-252-0106
Practice Address - Street 1:1919 BOSTON ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4160
Practice Address - Country:US
Practice Address - Phone:616-252-4787
Practice Address - Fax:616-252-6209
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI923878133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIN56710006Medicare ID - Type Unspecified