Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | 2015035182 | MO |
NPI | 1538694401 |
---|---|
Provider Name | Stephanie Young |
First Address | East Alton, IL 62024-1452 |
Second Address | East Alton, IL 62024-1452 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 27/04/2017 |
Last Update Date | 27/04/2017 |