Provider Demographics
NPI:1598120628
Name:MATLOCK, LACRYSTAL STRONG (MS, RD, LDN)
Entity Type:Individual
Prefix:MRS
First Name:LACRYSTAL
Middle Name:STRONG
Last Name:MATLOCK
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2300 RAMSEY ST
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28301-3856
Mailing Address - Country:US
Mailing Address - Phone:910-488-2120
Mailing Address - Fax:
Practice Address - Street 1:2300 RAMSEY ST
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28301-3856
Practice Address - Country:US
Practice Address - Phone:910-488-2120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-16
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003728133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered