Provider Demographics
NPI:1811319098
Name:SIMON, STACEY ELIZABETH (RD)
Entity type:Individual
Prefix:MS
First Name:STACEY
Middle Name:ELIZABETH
Last Name:SIMON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:STACEY
Other - Middle Name:ELIZABETH
Other - Last Name:RIGGS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:98 DEERFIELD LN N
Mailing Address - Street 2:
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10570-1406
Mailing Address - Country:US
Mailing Address - Phone:603-264-7382
Mailing Address - Fax:
Practice Address - Street 1:98 DEERFIELD LN N
Practice Address - Street 2:
Practice Address - City:PLEASANTVILLE
Practice Address - State:NY
Practice Address - Zip Code:10570-1406
Practice Address - Country:US
Practice Address - Phone:603-264-7382
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-08
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT88058133V00000X
NY86007711133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86007711OtherREGISTERED DIETITIAN