Basic Information
| Provider Information | |||||||||
| NPI: | 1487854410 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BUSEY | ||||||||
| FirstName: | STACEY | ||||||||
| MiddleName: | LYNN | ||||||||
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| Credential: | RD, CD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 602 E NOB HILL BLVD | ||||||||
| Address2: | WIC PROGRAM | ||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989013534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092488602 | ||||||||
| FaxNumber: | 5095774686 | ||||||||
| Practice Location | |||||||||
| Address1: | 602 E NOB HILL BLVD | ||||||||
| Address2: | WIC PROGRAM | ||||||||
| City: | YAKIMA | ||||||||
| State: | WA | ||||||||
| PostalCode: | 989013534 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5092488602 | ||||||||
| FaxNumber: | 5095774686 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2007 | ||||||||
| LastUpdateDate: | 07/18/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | DI00001545 | WA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 8415663 | 05 | WA | MEDICAID |