1821683822 NPI number — STEPHANIE LYNN COLACICCO NUTRITIONIST

Table of content: STEPHANIE LYNN COLACICCO NUTRITIONIST (NPI 1821683822)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1821683822 NPI number — STEPHANIE LYNN COLACICCO NUTRITIONIST

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
COLACICCO
Provider First Name:
STEPHANIE
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NUTRITIONIST
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
COLACICCO
Provider Other First Name:
STEPHANIE
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
STEPHANIE MAXWELL
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1821683822
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
33 MILLER RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
COLCHESTER
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06415-2707
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
860-808-7708
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
51 HAYWARD AVE APT 3A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLCHESTER
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06415-1288
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
860-808-7708
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/02/2021

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133N00000X , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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