Healthcare Provider Details

I. General information

NPI: 1811067341
Provider Name (Legal Business Name): TRACY ELAYNE STADLER RD, LD, CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

272 BENEDICT AVE
NORWALK OH
44857-2374
US

IV. Provider business mailing address

1722 SHEARWATER CIR E
HURON OH
44839-9131
US

V. Phone/Fax

Practice location:
  • Phone: 419-663-1975
  • Fax:
Mailing address:
  • Phone: 419-433-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3010
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: