Healthcare Provider Details

I. General information

NPI: 1174821425
Provider Name (Legal Business Name): STACY RENEE DEQUINA R.D., C.D.E.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2011
Last Update Date: 03/10/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20361 CLARK ST
WOODLAND HILLS CA
91367-5508
US

IV. Provider business mailing address

20361 CLARK ST
WOODLAND HILLS CA
91367-5508
US

V. Phone/Fax

Practice location:
  • Phone: 818-642-1494
  • Fax:
Mailing address:
  • Phone: 818-642-1494
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number859099
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: