Provider Demographics
NPI:1750049896
Name:BRACKBILL, STACY LYNN (RD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:BRACKBILL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 SEVILLA CT
Mailing Address - Street 2:
Mailing Address - City:YUBA CITY
Mailing Address - State:CA
Mailing Address - Zip Code:95993-1134
Mailing Address - Country:US
Mailing Address - Phone:408-640-8320
Mailing Address - Fax:
Practice Address - Street 1:481 PLUMAS BLVD STE 202
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-5075
Practice Address - Country:US
Practice Address - Phone:530-749-2409
Practice Address - Fax:530-751-4793
Is Sole Proprietor?:No
Enumeration Date:2021-12-06
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86041971133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered