Healthcare Provider Details

I. General information

NPI: 1245419878
Provider Name (Legal Business Name): STACY J PELLETIER R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/31/2007
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

44 S MAIN ST
RANDOLPH VT
05060-1381
US

IV. Provider business mailing address

44 S MAIN ST
RANDOLPH VT
05060-1381
US

V. Phone/Fax

Practice location:
  • Phone: 802-728-2260
  • Fax: 802-728-2613
Mailing address:
  • Phone: 802-728-2260
  • Fax: 802-728-2613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number074-0000213
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: