Provider Demographics
NPI:1316709454
Name:MOORE, STACI LYNN (RDN)
Entity type:Individual
Prefix:
First Name:STACI
Middle Name:LYNN
Last Name:MOORE
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2665 S CLARKSON ST
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80210-5803
Mailing Address - Country:US
Mailing Address - Phone:616-915-7925
Mailing Address - Fax:
Practice Address - Street 1:2665 S CLARKSON ST
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80210-5803
Practice Address - Country:US
Practice Address - Phone:616-915-7925
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-24
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO86302569133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered