Provider Demographics
NPI:1053868117
Name:AUSTIN, STACIE D (RDN LD)
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:D
Last Name:AUSTIN
Suffix:
Gender:F
Credentials:RDN LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 FORTUNE ROAD
Mailing Address - Street 2:C/O WIC NUTRITION SERVICE DEPARTMENT
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34744
Mailing Address - Country:US
Mailing Address - Phone:140-734-3200
Mailing Address - Fax:
Practice Address - Street 1:1875 FORTUNE RD
Practice Address - Street 2:C/O WIC NUTRITION SERVICE DEPARTMENT
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34744-4428
Practice Address - Country:US
Practice Address - Phone:140-734-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-07
Last Update Date:2016-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND7146133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered