Healthcare Provider Details

I. General information

NPI: 1235654922
Provider Name (Legal Business Name): STACEY BALA MS, RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/03/2017
Last Update Date: 02/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 WASHINGTON ST APT 103
RALEIGH NC
27605-3205
US

IV. Provider business mailing address

911 WASHINGTON ST APT 103
RALEIGH NC
27605-3205
US

V. Phone/Fax

Practice location:
  • Phone: 845-264-1199
  • Fax:
Mailing address:
  • Phone: 845-264-1199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberL004237
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: