Provider Demographics
NPI:1013239607
Name:O'DONNELL, STEPHANIE M (RD, LDN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:O'DONNELL
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 EDDY ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4739
Mailing Address - Country:US
Mailing Address - Phone:401-595-0434
Mailing Address - Fax:
Practice Address - Street 1:1000 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-4739
Practice Address - Country:US
Practice Address - Phone:401-533-9100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-23
Last Update Date:2011-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILDN00657133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered