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NPI Code Detail

MEDICARE: MRS. STACEY BRESHEARS MS, RD, CDCES

MEDICARE: MRS. STACEY BRESHEARS MS, RD, CDCES
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1133V00000XRegistered Dietitian

General Provider Information

NPI Number : 1619342573
Entity Type Code : Individual
Provider Name (Legal Business Name) : MRS. STACEY BRESHEARS MS, RD, CDCES
Provider Business Mailing Address
First Line : 1050 QUEEN ST STE 100
Second Line :
City : HONOLULU
State : HI
Zip : 96814-4130
Country : US
Telephone Number : 808-620-5553
Fax Number : 833-672-3405
Provider Business Practice Location Address
First Line : 1050 QUEEN ST STE 100
Second Line :
City : HONOLULU
State : HI
Zip : 96814-4130
Country : US
Telephone Number : 802-333-0057
Fax Number : 833-672-3405
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 12/03/2015
Last Update Date : 01/05/2024

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