Provider Demographics
NPI:1770098394
Name:PHILLIPS, STACY
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 124
Mailing Address - Street 2:
Mailing Address - City:MOFFETT FIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94035-0124
Mailing Address - Country:US
Mailing Address - Phone:805-704-7193
Mailing Address - Fax:
Practice Address - Street 1:571 ROCKROSE CT
Practice Address - Street 2:
Practice Address - City:INCLINE VILLAGE
Practice Address - State:NV
Practice Address - Zip Code:89451-8300
Practice Address - Country:US
Practice Address - Phone:805-704-7193
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-05
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCNU100000198133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist