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NPI Code Detail

MEDICARE: MAKENZIE STACY RD

MEDICARE: MAKENZIE STACY RD
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133V00000XRegistered Dietitian1895WV

General Provider Information

NPI Number : 1861325201
Entity Type Code : Individual
Provider Name (Legal Business Name) : MAKENZIE STACY RD
Provider Business Mailing Address
First Line : 98 FAIRFAX DR
Second Line :
City : HUNTINGTON
State : WV
Zip : 25705-1330
Country : US
Telephone Number : 681-203-6078
Fax Number :
Provider Business Practice Location Address
First Line : 98 FAIRFAX DR
Second Line :
City : HUNTINGTON
State : WV
Zip : 25705-1330
Country : US
Telephone Number : 681-203-6078
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/05/2026
Last Update Date : 06/05/2026

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Directions to “ MAKENZIE STACY RD” Practice Location

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