Provider Demographics
NPI:1760816839
Name:NUGEN, STEPHANIE LAYKISH (MS, RD, LDN, CDE)
Entity Type:Individual
Prefix:MS
First Name:STEPHANIE
Middle Name:LAYKISH
Last Name:NUGEN
Suffix:
Gender:F
Credentials:MS, RD, LDN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 629
Mailing Address - Street 2:211 VIRGINIA ROAD
Mailing Address - City:EDENTON
Mailing Address - State:NC
Mailing Address - Zip Code:27932-0629
Mailing Address - Country:US
Mailing Address - Phone:252-482-8451
Mailing Address - Fax:252-482-6224
Practice Address - Street 1:211 VIRGINIA RD
Practice Address - Street 2:
Practice Address - City:EDENTON
Practice Address - State:NC
Practice Address - Zip Code:27932-9668
Practice Address - Country:US
Practice Address - Phone:252-482-8451
Practice Address - Fax:252-482-6224
Is Sole Proprietor?:No
Enumeration Date:2013-08-26
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL000898133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered