Provider Demographics
NPI:1952830135
Name:TROFIMOV, STACI MARIE (MS, RD)
Entity Type:Individual
Prefix:MRS
First Name:STACI
Middle Name:MARIE
Last Name:TROFIMOV
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13008 WILLOW FOREST DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40245-1982
Mailing Address - Country:US
Mailing Address - Phone:903-742-5916
Mailing Address - Fax:
Practice Address - Street 1:13008 WILLOW FOREST DRIVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40245
Practice Address - Country:US
Practice Address - Phone:903-742-5916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY173141133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered