Provider Demographics
NPI:1780917237
Name:LUCCA, MARY (LICENSE DIETITIAN)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LUCCA
Suffix:
Gender:F
Credentials:LICENSE DIETITIAN
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:
Other - Last Name:INSALACO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICENSE DIETITIAN
Mailing Address - Street 1:2220 LEMP AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-2700
Mailing Address - Country:US
Mailing Address - Phone:314-814-8615
Mailing Address - Fax:314-814-8542
Practice Address - Street 1:100 N TUCKER BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63101-1931
Practice Address - Country:US
Practice Address - Phone:314-814-8556
Practice Address - Fax:314-814-8542
Is Sole Proprietor?:No
Enumeration Date:2009-09-16
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009014930133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist