Provider Demographics
NPI:1144320268
Name:FEDERICO, STACEY PANAGOTOPULOS (PHD,RD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:PANAGOTOPULOS
Last Name:FEDERICO
Suffix:
Gender:F
Credentials:PHD,RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 NEPONSET ST FL STREET2
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-2714
Mailing Address - Country:US
Mailing Address - Phone:508-368-5532
Mailing Address - Fax:
Practice Address - Street 1:24 NEWTON ST
Practice Address - Street 2:
Practice Address - City:SOUTHBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01772-1215
Practice Address - Country:US
Practice Address - Phone:508-460-3291
Practice Address - Fax:508-453-8152
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICDR963741133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered