Provider Demographics
NPI:1982292173
Name:BRISBON, LACIE
Entity Type:Individual
Prefix:
First Name:LACIE
Middle Name:
Last Name:BRISBON
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 1:13166 ODYSSEY LAKE WAY
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32826-4642
Mailing Address - Country:US
Mailing Address - Phone:407-455-8258
Mailing Address - Fax:
Practice Address - Street 1:13166 ODYSSEY LAKE WAY
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32826-4642
Practice Address - Country:US
Practice Address - Phone:407-455-8258
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-04
Last Update Date:2021-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11585133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist