Provider Demographics
NPI:1356882120
Name:FERNANDES, STEPHANIE (RDN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:FERNANDES
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:MIHALY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3205 CUMBERLAND BLVD SE UNIT 630
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30339-4431
Mailing Address - Country:US
Mailing Address - Phone:864-710-0140
Mailing Address - Fax:
Practice Address - Street 1:1000 BALLPARK WAY STE 400
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76011-5170
Practice Address - Country:US
Practice Address - Phone:864-710-0140
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-13
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86091322133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86091322OtherACADEMY OF NUTRITION AND DIETETICS
TXDT85680OtherTEXAS DEPARTMENT OF LICENSING AND REGULATION