Healthcare Provider Details

I. General information

NPI: 1285644575
Provider Name (Legal Business Name): TERESA LYNN STANLEY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 SPRING VALLEY DR (120)
HUNTINGTON WV
25704-9300
US

IV. Provider business mailing address

1540 SPRING VALLEY DR (120)
HUNTINGTON WV
25704-9300
US

V. Phone/Fax

Practice location:
  • Phone: 304-429-6741
  • Fax: 304-429-0264
Mailing address:
  • Phone: 304-429-6741
  • Fax: 304-429-0264

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number709024
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: