Provider Demographics
NPI:1649317199
Name:CRASE, STACY LYNETTE (RD)
Entity type:Individual
Prefix:MS
First Name:STACY
Middle Name:LYNETTE
Last Name:CRASE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 12TH ST
Mailing Address - Street 2:FOOTHILLS HEALTH AND WELLNESS CENTER
Mailing Address - City:CLAY CITY
Mailing Address - State:KY
Mailing Address - Zip Code:40312-8979
Mailing Address - Country:US
Mailing Address - Phone:606-663-9011
Mailing Address - Fax:606-663-9012
Practice Address - Street 1:108 12TH ST
Practice Address - Street 2:FOOTHILLS HEALTH AND WELLNESS CENTER
Practice Address - City:CLAY CITY
Practice Address - State:KY
Practice Address - Zip Code:40312-8979
Practice Address - Country:US
Practice Address - Phone:606-663-9011
Practice Address - Fax:606-663-9012
Is Sole Proprietor?:No
Enumeration Date:2007-01-31
Last Update Date:2012-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1672133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY20099016Medicaid
KY20099016Medicaid