Healthcare Provider Details

I. General information

NPI: 1649317199
Provider Name (Legal Business Name): STACY LYNETTE CRASE R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/31/2007
Last Update Date: 02/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 12TH ST FOOTHILLS HEALTH AND WELLNESS CENTER
CLAY CITY KY
40312-8979
US

IV. Provider business mailing address

108 12TH ST FOOTHILLS HEALTH AND WELLNESS CENTER
CLAY CITY KY
40312-8979
US

V. Phone/Fax

Practice location:
  • Phone: 606-663-9011
  • Fax: 606-663-9012
Mailing address:
  • Phone: 606-663-9011
  • Fax: 606-663-9012

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1672
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: