Provider Demographics
NPI:1629231683
Name:VANDERWEL, STACEY ANN (RD, CSP, LDN)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:ANN
Last Name:VANDERWEL
Suffix:
Gender:F
Credentials:RD, CSP, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7225 DELOACH CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-9514
Mailing Address - Country:US
Mailing Address - Phone:704-340-1604
Mailing Address - Fax:
Practice Address - Street 1:505 EAST BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5105
Practice Address - Country:US
Practice Address - Phone:704-542-2512
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-09
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002810133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric