Provider Demographics
NPI:1629621362
Name:ETHRIDGE, STACEY DUNN (MS, RDN, LDN)
Entity Type:Individual
Prefix:MRS
First Name:STACEY
Middle Name:DUNN
Last Name:ETHRIDGE
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:MS
Other - First Name:STACEY
Other - Middle Name:MICHELLE
Other - Last Name:DUNN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1216 SOMERVILLE RD SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-4335
Mailing Address - Country:US
Mailing Address - Phone:256-340-0012
Mailing Address - Fax:256-340-1408
Practice Address - Street 1:1216 SOMERVILLE RD SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-4335
Practice Address - Country:US
Practice Address - Phone:256-340-0012
Practice Address - Fax:256-340-1408
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2019-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2233133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered