Healthcare Provider Details

I. General information

NPI: 1265655005
Provider Name (Legal Business Name): STACEY LEE RICHMOND RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1170 MAIN ST
WEST BARNSTABLE MA
02668-1162
US

IV. Provider business mailing address

1170 MAIN ST
WEST BARNSTABLE MA
02668-1162
US

V. Phone/Fax

Practice location:
  • Phone: 508-362-1221
  • Fax: 508-362-5858
Mailing address:
  • Phone: 508-362-1221
  • Fax: 508-362-5858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1496
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: