Provider Demographics
NPI:1922478130
Name:PACKARD-FALES, LYNETTE (RD, CDCES, LMNT, LD)
Entity Type:Individual
Prefix:
First Name:LYNETTE
Middle Name:
Last Name:PACKARD-FALES
Suffix:
Gender:F
Credentials:RD, CDCES, LMNT, LD
Other - Prefix:
Other - First Name:LYNETTE
Other - Middle Name:
Other - Last Name:PACKARD-FALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, CDCES, LMNT, LD
Mailing Address - Street 1:201 N PLATT ST
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57702-0361
Mailing Address - Country:US
Mailing Address - Phone:308-708-9294
Mailing Address - Fax:
Practice Address - Street 1:113 COMANCHE RD
Practice Address - Street 2:
Practice Address - City:FORT MEADE
Practice Address - State:SD
Practice Address - Zip Code:57741-1002
Practice Address - Country:US
Practice Address - Phone:308-708-9294
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-30
Last Update Date:2024-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1228133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered