Provider Demographics
NPI:1457723611
Name:KIRCHEIN, STACEY
Entity Type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:KIRCHEIN
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 1:700 LOWER STATE RD
Mailing Address - Street 2:APT 18A1
Mailing Address - City:NORTH WALES
Mailing Address - State:PA
Mailing Address - Zip Code:19454
Mailing Address - Country:US
Mailing Address - Phone:631-553-7026
Mailing Address - Fax:
Practice Address - Street 1:700 LOWER STATE RD
Practice Address - Street 2:APT 18A1
Practice Address - City:NORTH WALES
Practice Address - State:PA
Practice Address - Zip Code:19454
Practice Address - Country:US
Practice Address - Phone:631-553-7026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN005376133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered