Provider Demographics
NPI:1821683822
Name:COLACICCO, STEPHANIE LYNN (NUTRITIONIST)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LYNN
Last Name:COLACICCO
Suffix:
Gender:F
Credentials:NUTRITIONIST
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:LYNN
Other - Last Name:COLACICCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:STEPHANIE MAXWELL
Mailing Address - Street 1:33 MILLER RD
Mailing Address - Street 2:
Mailing Address - City:COLCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06415-2707
Mailing Address - Country:US
Mailing Address - Phone:860-808-7708
Mailing Address - Fax:
Practice Address - Street 1:51 HAYWARD AVE APT 3A
Practice Address - Street 2:
Practice Address - City:COLCHESTER
Practice Address - State:CT
Practice Address - Zip Code:06415-1288
Practice Address - Country:US
Practice Address - Phone:860-808-7708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist