Provider Demographics
NPI:1841665684
Name:BAGANZ, STACEY (BCHN, MS)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:BAGANZ
Suffix:
Gender:F
Credentials:BCHN, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2499 LEDGER WAY
Mailing Address - Street 2:
Mailing Address - City:PARK CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84060-1220
Mailing Address - Country:US
Mailing Address - Phone:588-248-5343
Mailing Address - Fax:
Practice Address - Street 1:2499 LEDGER WAY
Practice Address - Street 2:
Practice Address - City:PARK CITY
Practice Address - State:UT
Practice Address - Zip Code:84060-1220
Practice Address - Country:US
Practice Address - Phone:858-248-5343
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-04
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist