Provider Demographics
NPI:1609060243
Name:WEDDINGTON, STACIE L (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:L
Last Name:WEDDINGTON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4542 UPPER JOHNS CREEK
Mailing Address - Street 2:
Mailing Address - City:KIMPER
Mailing Address - State:KY
Mailing Address - Zip Code:41539
Mailing Address - Country:US
Mailing Address - Phone:606-835-4708
Mailing Address - Fax:
Practice Address - Street 1:4542 UPPER JOHNS CREEK
Practice Address - Street 2:
Practice Address - City:KIMPER
Practice Address - State:KY
Practice Address - Zip Code:41539
Practice Address - Country:US
Practice Address - Phone:606-835-4708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-28
Last Update Date:2007-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1372133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered