Healthcare Provider Details

I. General information

NPI: 1003149311
Provider Name (Legal Business Name): STASHA KUCEL RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/18/2009
Last Update Date: 04/29/2020
Certification Date: 04/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 WHISTLER LN
PROSPER TX
75078-8672
US

IV. Provider business mailing address

920 WHISTLER LN
PROSPER TX
75078-8672
US

V. Phone/Fax

Practice location:
  • Phone: 214-326-2158
  • Fax:
Mailing address:
  • Phone: 214-326-2158
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT81272
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: