Provider Demographics
NPI:1639249717
Name:DEUTSCH, STACEY M (RD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:M
Last Name:DEUTSCH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:M
Other - Last Name:MARTIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:3003 W GOOD HOPE RD
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-2042
Mailing Address - Country:US
Mailing Address - Phone:414-352-3100
Mailing Address - Fax:
Practice Address - Street 1:N84W16889 MENOMONEE AVE
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-2810
Practice Address - Country:US
Practice Address - Phone:262-251-7500
Practice Address - Fax:262-251-7128
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2010-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1968133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIP00671031OtherRR MEDICARE
WI46236-0296Medicare PIN
WIP00671031OtherRR MEDICARE