Provider Demographics
NPI:1629081807
Name:MODICA, STEPHANIE (RD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:
Last Name:MODICA
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5850 CHEETAH CHASE
Mailing Address - Street 2:
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80124-9597
Mailing Address - Country:US
Mailing Address - Phone:720-841-7907
Mailing Address - Fax:303-683-6401
Practice Address - Street 1:7700 S BROADWAY
Practice Address - Street 2:
Practice Address - City:LITTLETON
Practice Address - State:CO
Practice Address - Zip Code:80122-2602
Practice Address - Country:US
Practice Address - Phone:720-841-7907
Practice Address - Fax:303-683-6401
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO890669133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO20320324OtherCOMISSION ON DIETETIC REG
CO890669OtherCOMISSION ON DIETETIC REG