Provider Demographics
NPI:1649522145
Name:MIRICH, STEPHANIE CHRISTINE (FNS)
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:CHRISTINE
Last Name:MIRICH
Suffix:
Gender:F
Credentials:FNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1709 VALLEY VIEW AVE
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94002-1939
Mailing Address - Country:US
Mailing Address - Phone:650-888-3632
Mailing Address - Fax:
Practice Address - Street 1:1709 VALLEY VIEW AVE
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:CA
Practice Address - Zip Code:94002-1939
Practice Address - Country:US
Practice Address - Phone:650-888-3632
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-08
Last Update Date:2012-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1427813133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist