Provider Demographics
NPI:1205374535
Name:STACY SMITH
Entity type:Organization
Organization Name:STACY SMITH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:STACY
Authorized Official - Middle Name:A
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:RD, RDN
Authorized Official - Phone:267-872-1093
Mailing Address - Street 1:3313 SHERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:DRESHER
Mailing Address - State:PA
Mailing Address - Zip Code:19025-1717
Mailing Address - Country:US
Mailing Address - Phone:267-872-1093
Mailing Address - Fax:
Practice Address - Street 1:3313 SHERWOOD LN
Practice Address - Street 2:
Practice Address - City:DRESHER
Practice Address - State:PA
Practice Address - Zip Code:19025-1717
Practice Address - Country:US
Practice Address - Phone:267-872-1093
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-07
Last Update Date:2017-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN005325261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service