Healthcare Provider Details

I. General information

NPI: 1669586533
Provider Name (Legal Business Name): MRS. GRETCHEN D'ANN STALTERS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 OLD RIVER RD SUITE B-2
LINCOLN RI
02865-1161
US

IV. Provider business mailing address

7 STONY FIELD RD
NORTON MA
02766-1145
US

V. Phone/Fax

Practice location:
  • Phone: 401-333-2784
  • Fax:
Mailing address:
  • Phone: 508-285-9383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLDN00363
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2464
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: