Provider Demographics
NPI:1689027583
Name:NELSON, STACY (RN, RD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:NELSON
Suffix:
Gender:F
Credentials:RN, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 W THOMAS RD
Mailing Address - Street 2:SUITE 600
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4224
Mailing Address - Country:US
Mailing Address - Phone:602-406-1140
Mailing Address - Fax:
Practice Address - Street 1:500 W THOMAS RD
Practice Address - Street 2:SUITE 600
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85013-4224
Practice Address - Country:US
Practice Address - Phone:602-406-1140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-15
Last Update Date:2016-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ863362133V00000X
AZRN079860163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No163W00000XNursing Service ProvidersRegistered Nurse