Provider Demographics
NPI:1619638236
Name:EDWARDS, STACY
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:EDWARDS
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 1:10638 HUNTERS CROSSING BLVD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46239-9747
Mailing Address - Country:US
Mailing Address - Phone:317-371-1437
Mailing Address - Fax:
Practice Address - Street 1:2424 21ST AVE S STE 201
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37212-5315
Practice Address - Country:US
Practice Address - Phone:615-861-9146
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-05
Last Update Date:2022-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN37003055A133V00000X
TNLDN0000004023133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered