Healthcare Provider Details

I. General information

NPI: 1154292415
Provider Name (Legal Business Name): STACEE RABER NAULT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2025
Last Update Date: 09/17/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

619 S SUNNYSIDE AVE
ELMHURST IL
60126-4208
US

IV. Provider business mailing address

619 S SUNNYSIDE AVE
ELMHURST IL
60126-4208
US

V. Phone/Fax

Practice location:
  • Phone: 206-235-3579
  • Fax:
Mailing address:
  • Phone: 206-235-3579
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: