Provider Demographics
NPI:1114110905
Name:WELLMAN, STACY LYNN (MS RD LD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:LYNN
Last Name:WELLMAN
Suffix:
Gender:F
Credentials:MS RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 MARKET ST
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WV
Mailing Address - Zip Code:26354-1184
Mailing Address - Country:US
Mailing Address - Phone:304-265-6436
Mailing Address - Fax:
Practice Address - Street 1:500 MARKET ST
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WV
Practice Address - Zip Code:26354-1184
Practice Address - Country:US
Practice Address - Phone:304-265-6436
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-24
Last Update Date:2008-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV481133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered