Provider Demographics
NPI:1609823087
Name:DEIVERT, STEPHANIE FLEETWOOD (RD)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:FLEETWOOD
Last Name:DEIVERT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:FLEETWOOD
Other - Last Name:YEAGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:CREDENTIALS DEPT
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:
Practice Address - Street 1:521 MT PLEASANT DR
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18503-1993
Practice Address - Country:US
Practice Address - Phone:570-342-8500
Practice Address - Fax:570-558-2290
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2020-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN003387133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q62164Medicare UPIN
PA097716Medicare ID - Type Unspecified