Provider Demographics
NPI:1194378869
Name:STOCKWELL-SUAREZ, CASSANDRA (RDN, IBCLC)
Entity type:Individual
Prefix:
First Name:CASSANDRA
Middle Name:
Last Name:STOCKWELL-SUAREZ
Suffix:
Gender:F
Credentials:RDN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:116 WALNUT AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:ARDMORE
Mailing Address - State:PA
Mailing Address - Zip Code:19003-2133
Mailing Address - Country:US
Mailing Address - Phone:619-569-7981
Mailing Address - Fax:
Practice Address - Street 1:116 WALNUT AVE APT 1
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:PA
Practice Address - Zip Code:19003-2133
Practice Address - Country:US
Practice Address - Phone:619-569-7981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-22
Last Update Date:2022-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133V00000X
L-305901174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty