Provider Demographics
NPI:1225857113
Name:GILL, STACY MICHELLE (RD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:MICHELLE
Last Name:GILL
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 1:14743 E CRESTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80015-4295
Mailing Address - Country:US
Mailing Address - Phone:303-319-8383
Mailing Address - Fax:
Practice Address - Street 1:14743 E CRESTRIDGE DR
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80015-4295
Practice Address - Country:US
Practice Address - Phone:303-319-8383
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-08
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT91131133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty