Provider Demographics
NPI:1649486473
Name:CHAU, STACEY PHUONG (MS, RD)
Entity type:Individual
Prefix:
First Name:STACEY
Middle Name:PHUONG
Last Name:CHAU
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4759 MOUNTAIRE PL
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95138-2715
Mailing Address - Country:US
Mailing Address - Phone:408-603-3730
Mailing Address - Fax:
Practice Address - Street 1:250 HOSPITAL PKWY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95119-1103
Practice Address - Country:US
Practice Address - Phone:408-972-7240
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00952078133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered