Provider Demographics
NPI:1457828857
Name:LASELL, MADELINE P
Entity Type:Individual
Prefix:
First Name:MADELINE
Middle Name:P
Last Name:LASELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:721 OKATIE HWY # 170
Mailing Address - Street 2:
Mailing Address - City:OKATIE
Mailing Address - State:SC
Mailing Address - Zip Code:29909-3963
Mailing Address - Country:US
Mailing Address - Phone:843-987-7400
Mailing Address - Fax:
Practice Address - Street 1:1520 GRAYS HWY
Practice Address - Street 2:
Practice Address - City:RIDGELAND
Practice Address - State:SC
Practice Address - Zip Code:29936-5440
Practice Address - Country:US
Practice Address - Phone:843-726-3979
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1851133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered