Provider Demographics
NPI:1912034018
Name:TROGDON, STACEY (RD)
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:TROGDON
Suffix:
Gender:F
Credentials:RD
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 3867
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99220-3867
Mailing Address - Country:US
Mailing Address - Phone:509-688-6700
Mailing Address - Fax:509-688-6777
Practice Address - Street 1:6120 N MAYFAIR ST
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99208-1033
Practice Address - Country:US
Practice Address - Phone:509-688-6700
Practice Address - Fax:509-484-9212
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAD100001085133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2087263Medicaid
WA2087263Medicaid