Provider Demographics
NPI:1306180286
Name:WOOD, STACEY (RDLD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:
Last Name:WOOD
Suffix:
Gender:F
Credentials:RDLD
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 856
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76086-0856
Mailing Address - Country:US
Mailing Address - Phone:817-381-8679
Mailing Address - Fax:817-381-4159
Practice Address - Street 1:971 HILLTOP DR
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76086-5845
Practice Address - Country:US
Practice Address - Phone:817-602-5909
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-16
Last Update Date:2023-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT06458133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX308471701Medicaid
TX8DN488OtherBCBS