Provider Demographics
NPI:1720604358
Name:STOCKERT, GRACE (RDN)
Entity Type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:STOCKERT
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15240 WARWICK DR NW
Mailing Address - Street 2:
Mailing Address - City:CANAL FULTON
Mailing Address - State:OH
Mailing Address - Zip Code:44614-8524
Mailing Address - Country:US
Mailing Address - Phone:330-936-7125
Mailing Address - Fax:
Practice Address - Street 1:2821 WOODLAWN AVE NW
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-1423
Practice Address - Country:US
Practice Address - Phone:330-479-4800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-19
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH86094757133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered