Provider Demographics
NPI:1194547323
Name:STACY, REBEKAH (RD)
Entity type:Individual
Prefix:
First Name:REBEKAH
Middle Name:
Last Name:STACY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2709
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75606-2709
Mailing Address - Country:US
Mailing Address - Phone:903-234-0776
Mailing Address - Fax:903-234-9769
Practice Address - Street 1:409 N 6TH ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75601-6536
Practice Address - Country:US
Practice Address - Phone:903-501-1747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-29
Last Update Date:2024-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT84347133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered