Provider Demographics
NPI:1558060475
Name:IRETON, LACEY JULIA-ANN (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:LACEY
Middle Name:JULIA-ANN
Last Name:IRETON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:MS
Other - First Name:LACEY
Other - Middle Name:JULIA-ANN
Other - Last Name:JOHNSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1945 S DENENE ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67209-1974
Mailing Address - Country:US
Mailing Address - Phone:316-993-2046
Mailing Address - Fax:
Practice Address - Street 1:5500 E KELLOGG DR
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67218-1607
Practice Address - Country:US
Practice Address - Phone:316-686-2221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-28
Last Update Date:2023-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS2208133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered