Basic Information
| Provider Information | |||||||||
| NPI: | 1053746164 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAXLEY | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | CHEKOS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | R.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CHEKOS | ||||||||
| OtherFirstName: | STEPHANIE | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 955 RIBAUT ROAD | ||||||||
| Address2: | BMAC CREDENTIALING COORDINATOR | ||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 299025441 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435225674 | ||||||||
| FaxNumber: | 8435225678 | ||||||||
| Practice Location | |||||||||
| Address1: | 955 RIBAUT RD | ||||||||
| Address2: | |||||||||
| City: | BEAUFORT | ||||||||
| State: | SC | ||||||||
| PostalCode: | 29902 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8435225200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/09/2013 | ||||||||
| LastUpdateDate: | 07/23/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | LD004069 | GA | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133V00000X | 1605 | SC | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | DT1146 | 05 | SC | MEDICAID |