Provider Demographics
NPI:1346291333
Name:KISVER, STACIE R (RD)
Entity type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:R
Last Name:KISVER
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 1:147 KINGSCLERE DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAMPTON
Mailing Address - State:PA
Mailing Address - Zip Code:18966-3077
Mailing Address - Country:US
Mailing Address - Phone:215-953-8336
Mailing Address - Fax:
Practice Address - Street 1:714 N BETHLEHEM PIKE
Practice Address - Street 2:SUITE 300
Practice Address - City:LOWER GWYNEDD
Practice Address - State:PA
Practice Address - Zip Code:19002-2655
Practice Address - Country:US
Practice Address - Phone:215-283-2833
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN001538133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA058101POQMedicare ID - Type Unspecified