Provider Demographics
NPI:1518201581
Name:RABURN, LACEY MCDONOUGH (MS, RD, CLC, LDN)
Entity Type:Individual
Prefix:
First Name:LACEY
Middle Name:MCDONOUGH
Last Name:RABURN
Suffix:
Gender:F
Credentials:MS, RD, CLC, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3234 MILLER AVE
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38555-6116
Mailing Address - Country:US
Mailing Address - Phone:931-707-8700
Mailing Address - Fax:
Practice Address - Street 1:3234 MILLER AVE
Practice Address - Street 2:
Practice Address - City:CROSSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38555-6116
Practice Address - Country:US
Practice Address - Phone:931-707-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLDN0000002414133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered