Provider Demographics
NPI:1710638051
Name:FOGARTY-BROWN, STACEY LYNN (RD, CSP)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:LYNN
Last Name:FOGARTY-BROWN
Suffix:
Gender:F
Credentials:RD, CSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8214 VALLEYVIEW DR
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-8362
Mailing Address - Country:US
Mailing Address - Phone:989-330-1789
Mailing Address - Fax:
Practice Address - Street 1:8214 VALLEYVIEW DR
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-8362
Practice Address - Country:US
Practice Address - Phone:989-330-1789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-18
Last Update Date:2022-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86057543133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric