Healthcare Provider Details

I. General information

NPI: 1700158490
Provider Name (Legal Business Name): STACY LEIGH MICHAEL RDLD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACY LEIGH CLUXTON RDLD

II. Dates (important events)

Enumeration Date: 01/27/2012
Last Update Date: 01/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 KENTON STATION DR
MAYSVILLE KY
41056-9617
US

IV. Provider business mailing address

PO BOX 550
VANCEBURG KY
41179-0550
US

V. Phone/Fax

Practice location:
  • Phone: 606-759-5331
  • Fax: 606-759-5363
Mailing address:
  • Phone: 606-796-3029
  • Fax: 606-796-6221

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2229
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: