Provider Demographics
NPI:1922243419
Name:STOGSDILL, GRACEN (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:GRACEN
Middle Name:
Last Name:STOGSDILL
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 1:2015 STONEY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72211-5475
Mailing Address - Country:US
Mailing Address - Phone:501-351-7633
Mailing Address - Fax:
Practice Address - Street 1:4301 W MARKHAM ST
Practice Address - Street 2:SLOT 574-01
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:501-686-5788
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR985133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered