Healthcare Provider Details

I. General information

NPI: 1184671505
Provider Name (Legal Business Name): DEBORA LOUISE STUPIC RD LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2006
Last Update Date: 12/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1099 OAK ST
INDIANA PA
15701-1651
US

IV. Provider business mailing address

1099 OAK ST
INDIANA PA
15701-1651
US

V. Phone/Fax

Practice location:
  • Phone: 844-328-9473
  • Fax: 724-224-0749
Mailing address:
  • Phone: 844-328-9473
  • Fax: 724-224-0749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License NumberDN001744
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDN001744
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: