Provider Demographics
NPI:1013257351
Name:HUNTER, STACIE ANNE (RD)
Entity Type:Individual
Prefix:
First Name:STACIE
Middle Name:ANNE
Last Name:HUNTER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 W TUCKER BLVD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:TX
Mailing Address - Zip Code:76013
Mailing Address - Country:US
Mailing Address - Phone:817-791-6263
Mailing Address - Fax:
Practice Address - Street 1:1935 MEDICAL DISTRICT DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7701
Practice Address - Country:US
Practice Address - Phone:217-456-2178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-24
Last Update Date:2015-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005845133V00000X
TXDT83045133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
8EK221OtherBLUE CROSS BLUE SHIELD
TX330110301Medicaid