Provider Demographics
NPI:1609527233
Name:MILLER, STACI BRECKENRIDGE
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:BRECKENRIDGE
Last Name:MILLER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1451 QUAIL ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2742
Mailing Address - Country:US
Mailing Address - Phone:949-290-6353
Mailing Address - Fax:
Practice Address - Street 1:1451 QUAIL ST
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2742
Practice Address - Country:US
Practice Address - Phone:949-290-6353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-14
Last Update Date:2022-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist