Provider Demographics
NPI:1649848466
Name:GASTON, STEPHANIE SUSANNA (RDN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:SUSANNA
Last Name:GASTON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:SUSANNA
Other - Last Name:TEAGUE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3520 BURNS TRL
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37419-1202
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:975 E 3RD ST
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37403-2147
Practice Address - Country:US
Practice Address - Phone:423-505-4928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-17
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN86291517133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN86291517OtherCOMMISSION ON DIETETIC REGISTRATION