Basic Information
| Provider Information | |||||||||
| NPI: | 1700158490 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MICHAEL | ||||||||
| FirstName: | STACY | ||||||||
| MiddleName: | LEIGH | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RDLD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CLUXTON | ||||||||
| OtherFirstName: | STACY | ||||||||
| OtherMiddleName: | LEIGH | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | RDLD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 550 | ||||||||
| Address2: | |||||||||
| City: | VANCEBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 411790550 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067963029 | ||||||||
| FaxNumber: | 6067966221 | ||||||||
| Practice Location | |||||||||
| Address1: | 927 KENTON STATION DR | ||||||||
| Address2: | |||||||||
| City: | MAYSVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 410569617 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6067595331 | ||||||||
| FaxNumber: | 6067595363 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/27/2012 | ||||||||
| LastUpdateDate: | 01/27/2012 | ||||||||
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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 | 2229 | KY | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.