Provider Demographics
NPI:1811664915
Name:FUNAIR, LACEY (MS,RDN,CDCES,BC-ADM)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:FUNAIR
Suffix:
Gender:F
Credentials:MS,RDN,CDCES,BC-ADM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:405 HAZEL ST
Mailing Address - Street 2:
Mailing Address - City:ZELIENOPLE
Mailing Address - State:PA
Mailing Address - Zip Code:16063-1016
Mailing Address - Country:US
Mailing Address - Phone:724-900-9075
Mailing Address - Fax:724-382-7709
Practice Address - Street 1:405 HAZEL ST
Practice Address - Street 2:
Practice Address - City:ZELIENOPLE
Practice Address - State:PA
Practice Address - Zip Code:16063-1016
Practice Address - Country:US
Practice Address - Phone:724-900-9075
Practice Address - Fax:724-382-7709
Is Sole Proprietor?:No
Enumeration Date:2021-08-26
Last Update Date:2024-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CBDCE22200462174400000X
BCADM200914796174400000X
174H00000X
PADN005678133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174400000XOther Service ProvidersSpecialist
No174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1039464260002Medicaid