Provider Demographics
NPI:1538282330
Name:NORDSIDEN, LACEY ANN (ATC)
Entity Type:Individual
Prefix:MS
First Name:LACEY
Middle Name:ANN
Last Name:NORDSIDEN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:566 VIRGINIAN DR
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23505-4243
Mailing Address - Country:US
Mailing Address - Phone:757-642-2052
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY PL
Practice Address - Street 2:CHRISTOPHER NEWPORT UNIVERSITY - DEPT OF ATHLETICS
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2949
Practice Address - Country:US
Practice Address - Phone:757-286-2389
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01260009062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer