Provider Demographics
NPI:1679929830
Name:FELICIANO, STEPHANIE SAULLO (MS, RD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SAULLO
Last Name:FELICIANO
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:SAULLO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, RD
Mailing Address - Street 1:5819 CREOLA RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-5223
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1212 MANN DR STE 100
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-5511
Practice Address - Country:US
Practice Address - Phone:980-292-0239
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-06
Last Update Date:2019-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC100000406133V00000X
NCL004596133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered