Provider Demographics
NPI:1679152862
Name:PETROSKY, STEPHANIE NELSON (RDN)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:NELSON
Last Name:PETROSKY
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7600 SW 36TH ST
Mailing Address - Street 2:DEPARTMENT OF NUTRITION
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33328-1902
Mailing Address - Country:US
Mailing Address - Phone:954-262-1597
Mailing Address - Fax:
Practice Address - Street 1:3200 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2018
Practice Address - Country:US
Practice Address - Phone:954-262-1597
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND000373133N00000X, 133VN1004X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
No133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric