Provider Demographics
NPI:1336545318
Name:VEVEA, STACY (MS, RDN, LD)
Entity Type:Individual
Prefix:MRS
First Name:STACY
Middle Name:
Last Name:VEVEA
Suffix:
Gender:F
Credentials:MS, RDN, LD
Other - Prefix:MISS
Other - First Name:STACY
Other - Middle Name:
Other - Last Name:DALTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1920 GRANT ST NW
Mailing Address - Street 2:
Mailing Address - City:FARIBAULT
Mailing Address - State:MN
Mailing Address - Zip Code:55021-4831
Mailing Address - Country:US
Mailing Address - Phone:507-334-2085
Mailing Address - Fax:
Practice Address - Street 1:1920 GRANT ST NW
Practice Address - Street 2:
Practice Address - City:FARIBAULT
Practice Address - State:MN
Practice Address - Zip Code:55021-4831
Practice Address - Country:US
Practice Address - Phone:507-334-2085
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-11-18
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN3452133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered