Provider Demographics
NPI:1285916262
Name:WALDEN, STACI H (MSCN, RD/LDN,)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:H
Last Name:WALDEN
Suffix:
Gender:F
Credentials:MSCN, RD/LDN,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 ACADEMY ST
Mailing Address - Street 2:
Mailing Address - City:CAMBRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21613-1958
Mailing Address - Country:US
Mailing Address - Phone:410-228-2474
Mailing Address - Fax:
Practice Address - Street 1:417 ACADEMY ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-1958
Practice Address - Country:US
Practice Address - Phone:410-228-2474
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-15
Last Update Date:2019-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX3200133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered