Healthcare Provider Details

I. General information

NPI: 1760874150
Provider Name (Legal Business Name): STACEY L MESSE RD, CDN, CNSC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2015
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 IRVING AVE SUITE 504
SYRACUSE NY
13210-1603
US

IV. Provider business mailing address

341 WOODBINE AVE
SYRACUSE NY
13206-3325
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-4835
  • Fax:
Mailing address:
  • Phone: 404-295-2609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number48-007255
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: