Provider Demographics
NPI:1245872985
Name:STRUHAR, STACEY JULIA
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:JULIA
Last Name:STRUHAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 917770
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32891-0001
Mailing Address - Country:US
Mailing Address - Phone:813-974-2201
Mailing Address - Fax:813-974-4325
Practice Address - Street 1:4202 E FOWLER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33620-8000
Practice Address - Country:US
Practice Address - Phone:813-974-2201
Practice Address - Fax:813-974-4325
Is Sole Proprietor?:No
Enumeration Date:2019-10-15
Last Update Date:2019-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND9288133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLLY123OtherMEDICARE
FLGWS55OtherBLUE CROSS BLUE SHIELD