Provider Demographics
NPI:1346077690
Name:DAVIDSON, STACI LEAVITT (RD)
Entity type:Individual
Prefix:MRS
First Name:STACI
Middle Name:LEAVITT
Last Name:DAVIDSON
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 1:27 MCGOVERN DR
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-4258
Mailing Address - Country:US
Mailing Address - Phone:516-433-1456
Mailing Address - Fax:
Practice Address - Street 1:27 MCGOVERN DR
Practice Address - Street 2:
Practice Address - City:MELVILLE
Practice Address - State:NY
Practice Address - Zip Code:11747-4258
Practice Address - Country:US
Practice Address - Phone:516-433-1456
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-18
Last Update Date:2024-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00031001133V00000X
NY000310-01133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered