Provider Demographics
NPI:1407012321
Name:PETERS, STACY D (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:D
Last Name:PETERS
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 79TH PL
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79423-2409
Mailing Address - Country:US
Mailing Address - Phone:806-470-3489
Mailing Address - Fax:806-687-7778
Practice Address - Street 1:4810 N LOOP 289
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79416-3025
Practice Address - Country:US
Practice Address - Phone:806-472-5325
Practice Address - Fax:806-687-7778
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-30
Last Update Date:2008-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT07584133V00000X
NMLD0639133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered