Provider Demographics
NPI:1770966905
Name:BAKER, LACEY ANDERSON (RD, CSP, LD, CNSC)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:ANDERSON
Last Name:BAKER
Suffix:
Gender:F
Credentials:RD, CSP, LD, CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1289
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33601-1289
Mailing Address - Country:US
Mailing Address - Phone:813-844-8927
Mailing Address - Fax:
Practice Address - Street 1:5 TAMPA GENERAL CIR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33606-3601
Practice Address - Country:US
Practice Address - Phone:813-844-7473
Practice Address - Fax:813-844-1966
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-07
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7706133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered