Provider Demographics
NPI:1962159384
Name:STACEY SIMON NUTRITION LLC
Entity type:Organization
Organization Name:STACEY SIMON NUTRITION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGISTERED DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:ELIZABETH
Authorized Official - Last Name:SIMON
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:603-264-7382
Mailing Address - Street 1:98 DEERFIELD LN N
Mailing Address - Street 2:
Mailing Address - City:PLEASANTVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:10570-1406
Mailing Address - Country:US
Mailing Address - Phone:603-264-7382
Mailing Address - Fax:
Practice Address - Street 1:98 DEERFIELD LN N
Practice Address - Street 2:
Practice Address - City:PLEASANTVILLE
Practice Address - State:NY
Practice Address - Zip Code:10570-1406
Practice Address - Country:US
Practice Address - Phone:603-264-7382
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-05
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6303777OtherCIGNA