Provider Demographics
NPI:1972925022
Name:VANBIBBER, STACY (MS, RD, LD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:VANBIBBER
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1457 CAMBRIDGE LAKES DR
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7301
Mailing Address - Country:US
Mailing Address - Phone:304-552-4406
Mailing Address - Fax:
Practice Address - Street 1:1457 CAMBRIDGE LAKES DR
Practice Address - Street 2:
Practice Address - City:MOUNT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-7301
Practice Address - Country:US
Practice Address - Phone:304-552-4406
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-08
Last Update Date:2014-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC675133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
963327OtherCDR