Provider Demographics
NPI:1811231863
Name:SHACTER, STACI (RD MS LDN)
Entity Type:Individual
Prefix:
First Name:STACI
Middle Name:
Last Name:SHACTER
Suffix:
Gender:F
Credentials:RD MS LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3497 BARBADOS AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33026-4653
Mailing Address - Country:US
Mailing Address - Phone:954-290-9598
Mailing Address - Fax:
Practice Address - Street 1:2320 NE 62ND ST
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33308-2208
Practice Address - Country:US
Practice Address - Phone:954-772-7552
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND5654133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered