Provider Demographics
NPI:1053746164
Name:BAXLEY, STEPHANIE CHEKOS (RD)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:CHEKOS
Last Name:BAXLEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:STEPHANIE
Other - Middle Name:
Other - Last Name:CHEKOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:955 RIBAUT ROAD
Mailing Address - Street 2:BMAC CREDENTIALING COORDINATOR
Mailing Address - City:BEAUFORT
Mailing Address - State:SC
Mailing Address - Zip Code:29902-5441
Mailing Address - Country:US
Mailing Address - Phone:843-522-5674
Mailing Address - Fax:843-522-5678
Practice Address - Street 1:955 RIBAUT RD
Practice Address - Street 2:
Practice Address - City:BEAUFORT
Practice Address - State:SC
Practice Address - Zip Code:29902
Practice Address - Country:US
Practice Address - Phone:843-522-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-09
Last Update Date:2019-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD004069133V00000X
SC1605133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCDT1146Medicaid