Provider Demographics
NPI:1548632136
Name:SCHALLER, STACIE RENEE (RD)
Entity type:Individual
Prefix:MRS
First Name:STACIE
Middle Name:RENEE
Last Name:SCHALLER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:STACIE
Other - Middle Name:RENEE
Other - Last Name:SCHUTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, LDN
Mailing Address - Street 1:919 N HONORE ST # 2N
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60622-4929
Mailing Address - Country:US
Mailing Address - Phone:317-557-1716
Mailing Address - Fax:
Practice Address - Street 1:225 E CHICAGO AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2991
Practice Address - Country:US
Practice Address - Phone:312-227-4152
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-22
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164005765133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric