Provider Demographics
NPI:1548693211
Name:LEUNG, STACY K (RDN, CDN)
Entity type:Individual
Prefix:
First Name:STACY
Middle Name:K
Last Name:LEUNG
Suffix:
Gender:F
Credentials:RDN, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6615 246TH ST
Mailing Address - Street 2:
Mailing Address - City:LITTLE NECK
Mailing Address - State:NY
Mailing Address - Zip Code:11362-2340
Mailing Address - Country:US
Mailing Address - Phone:917-882-4697
Mailing Address - Fax:
Practice Address - Street 1:6615 246TH ST
Practice Address - Street 2:
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11362-2340
Practice Address - Country:US
Practice Address - Phone:917-882-4697
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-16
Last Update Date:2020-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133NN1002X
1046501133V00000X
NY007482133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00695941Medicaid
NYG100000410Medicare Oscar/Certification
NY331009Medicare Oscar/Certification