Provider Demographics
NPI:1033667704
Name:SUDJIAN, STEPHANIE
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:SUDJIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:755 W LANCASTER AVE # 1171
Mailing Address - Street 2:
Mailing Address - City:BRYN MAWR
Mailing Address - State:PA
Mailing Address - Zip Code:19010-3401
Mailing Address - Country:US
Mailing Address - Phone:508-907-8850
Mailing Address - Fax:
Practice Address - Street 1:755 W LANCASTER AVE # 1171
Practice Address - Street 2:
Practice Address - City:BRYN MAWR
Practice Address - State:PA
Practice Address - Zip Code:19010-3401
Practice Address - Country:US
Practice Address - Phone:508-907-8850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-12
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4137133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered