Provider Demographics
NPI:1902351695
Name:PAVER, STEPHANIE MARIE (RD)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:MARIE
Last Name:PAVER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 E COLTER ST
Mailing Address - Street 2:UNIT 240
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85016-3363
Mailing Address - Country:US
Mailing Address - Phone:815-347-4655
Mailing Address - Fax:
Practice Address - Street 1:1701 E COLTER ST
Practice Address - Street 2:UNIT 240
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85016-3363
Practice Address - Country:US
Practice Address - Phone:815-347-4655
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-23
Last Update Date:2016-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1015582133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered