Provider Demographics
NPI:1467613661
Name:LUECK, STACY (RD)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:
Last Name:LUECK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4003 E FUNK AVE
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99223-5356
Mailing Address - Country:US
Mailing Address - Phone:509-921-6560
Mailing Address - Fax:509-921-6551
Practice Address - Street 1:11703 E SPRAGUE AVE STE C3
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99206-6129
Practice Address - Country:US
Practice Address - Phone:509-921-6560
Practice Address - Fax:509-921-6551
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2008-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAD100001230133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAD100001230OtherWA CERTIFICATION NUMBER
WA9051731Medicaid
WA00851672OtherADA NUMBER
WA8261471OtherPROVIDER NUMBER
WA00851672OtherADA NUMBER