Provider Demographics
NPI:1700158490
Name:MICHAEL, STACY LEIGH (RDLD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:LEIGH
Last Name:MICHAEL
Suffix:
Gender:F
Credentials:RDLD
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:LEIGH
Other - Last Name:CLUXTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDLD
Mailing Address - Street 1:PO BOX 550
Mailing Address - Street 2:
Mailing Address - City:VANCEBURG
Mailing Address - State:KY
Mailing Address - Zip Code:41179-0550
Mailing Address - Country:US
Mailing Address - Phone:606-796-3029
Mailing Address - Fax:606-796-6221
Practice Address - Street 1:927 KENTON STATION DR
Practice Address - Street 2:
Practice Address - City:MAYSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41056-9617
Practice Address - Country:US
Practice Address - Phone:606-759-5331
Practice Address - Fax:606-759-5363
Is Sole Proprietor?:No
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2229133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered