Healthcare Provider Details

I. General information

NPI: 1528516002
Provider Name (Legal Business Name): STACY ANN ZELL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2016
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2780 CLEVELAND AVE
FORT MYERS FL
33901-5858
US

IV. Provider business mailing address

PO BOX 2147
FORT MYERS FL
33902-2147
US

V. Phone/Fax

Practice location:
  • Phone: 239-343-3831
  • Fax:
Mailing address:
  • Phone: 239-424-3120
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND2477
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: