Healthcare Provider Details

I. General information

NPI: 1033539291
Provider Name (Legal Business Name): STACY SPADARO RD, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/25/2014
Last Update Date: 01/16/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11565 PERRY HWY SUITE 1B
WEXFORD PA
15090-8799
US

IV. Provider business mailing address

11565 PERRY HWY SUITE 1B
WEXFORD PA
15090-8799
US

V. Phone/Fax

Practice location:
  • Phone: 412-852-3165
  • Fax:
Mailing address:
  • Phone: 412-852-3165
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License NumberDN005206
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: