Provider Demographics
NPI:1679715296
Name:KING, STEPHANIE MICHELLE (MS, RD)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:MICHELLE
Last Name:KING
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:237 TROUT LAKE DR
Mailing Address - Street 2:
Mailing Address - City:SANGER
Mailing Address - State:CA
Mailing Address - Zip Code:93657-9102
Mailing Address - Country:US
Mailing Address - Phone:559-787-2333
Mailing Address - Fax:
Practice Address - Street 1:237 TROUT LAKE DR
Practice Address - Street 2:
Practice Address - City:SANGER
Practice Address - State:CA
Practice Address - Zip Code:93657-9102
Practice Address - Country:US
Practice Address - Phone:559-787-2333
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-27
Last Update Date:2009-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA949615133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered