Basic Information
| Provider Information | |||||||||
| NPI: | 1932390275 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SOUTHALL | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | RD, LD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 18777 MIDWAY RD APT 1310 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752872742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8178918722 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1353 N WESTMORELAND RD BLDG F | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752111655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2143337091 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2007 | ||||||||
| LastUpdateDate: | 01/16/2009 | ||||||||
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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 | DT80516 | TX | N | Dietary & Nutritional Service Providers | Dietitian, Registered | 133VN1004X | DT80516 | TX | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric |
No ID Information.