Provider Demographics
NPI:1629250964
Name:HICKEL, STACEY (RD)
Entity Type:Individual
Prefix:MISS
First Name:STACEY
Middle Name:
Last Name:HICKEL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4851 KOKOMO DR
Mailing Address - Street 2:#7324
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95835-1840
Mailing Address - Country:US
Mailing Address - Phone:916-470-9715
Mailing Address - Fax:
Practice Address - Street 1:2221 STOCKTON BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-1418
Practice Address - Country:US
Practice Address - Phone:916-734-6528
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-28
Last Update Date:2007-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA881956133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal