Provider Demographics
NPI:1902408701
Name:CONTRERAS, STEPHANIE HALEY VIOLET (RD, LD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:HALEY VIOLET
Last Name:CONTRERAS
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2532 N TRAFALGER DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72704-6090
Mailing Address - Country:US
Mailing Address - Phone:479-652-5711
Mailing Address - Fax:
Practice Address - Street 1:215 N EAST AVE STE 102
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72701-5296
Practice Address - Country:US
Practice Address - Phone:479-652-5711
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1979133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered