Provider Demographics
NPI:1013328848
Name:HALL, LACEY (RD)
Entity Type:Individual
Prefix:MS
First Name:LACEY
Middle Name:
Last Name:HALL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:271 HAWKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46385-8167
Mailing Address - Country:US
Mailing Address - Phone:312-620-0116
Mailing Address - Fax:
Practice Address - Street 1:271 HAWKWOOD DR
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46385-8167
Practice Address - Country:US
Practice Address - Phone:312-620-0116
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-14
Last Update Date:2014-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN164005106133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered