Provider Demographics
NPI:1962660506
Name:STEFANSKI, CONNIE JEAN (RD)
Entity Type:Individual
Prefix:MRS
First Name:CONNIE
Middle Name:JEAN
Last Name:STEFANSKI
Suffix:
Gender:F
Credentials:RD
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Mailing Address - Street 1:11800 E 12 MILE ROAD
Mailing Address - Street 2:ST JOHN MACOMB HOSPITAL PT EDUCATION DEPT MEC
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-3472
Mailing Address - Country:US
Mailing Address - Phone:586-573-5697
Mailing Address - Fax:586-576-4119
Practice Address - Street 1:11800 E 12 MILE ROAD
Practice Address - Street 2:ST JOHN MACOMB HOSPITAL PT EDUCATION DEPT MEC
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3472
Practice Address - Country:US
Practice Address - Phone:586-573-5697
Practice Address - Fax:586-576-4119
Is Sole Proprietor?:No
Enumeration Date:2008-05-30
Last Update Date:2008-05-30
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI712110133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MION75100Medicare PIN