Provider Demographics
NPI:1851645485
Name:TUBIN, STEFANIE BLAKE (RD, CDN, IBCLC)
Entity Type:Individual
Prefix:MRS
First Name:STEFANIE
Middle Name:BLAKE
Last Name:TUBIN
Suffix:
Gender:F
Credentials:RD, CDN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9070 MICHAEL DOUGLAS DR
Mailing Address - Street 2:
Mailing Address - City:CLARENCE CENTER
Mailing Address - State:NY
Mailing Address - Zip Code:14032-9276
Mailing Address - Country:US
Mailing Address - Phone:716-741-0107
Mailing Address - Fax:
Practice Address - Street 1:9070 MICHAEL DOUGLAS DR
Practice Address - Street 2:
Practice Address - City:CLARENCE CENTER
Practice Address - State:NY
Practice Address - Zip Code:14032-9276
Practice Address - Country:US
Practice Address - Phone:716-741-0107
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY807729133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered