MEDICARE: LACY MAQUEL PUTTUCK R.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	V109666	OTHER	NV	SMA MEDICARE PIN

General Provider Information

NPI Number	:	1366719312
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LACY MAQUEL PUTTUCK R.D.

Provider Business Mailing Address
First Line	:	6171 MCLEOD DR STE A
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-4410
Country	:	US
Telephone Number	:	702-567-3495
Fax Number	:

Provider Business Practice Location Address
First Line	:	6171 MCLEOD DR STE A
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89120-4410
Country	:	US
Telephone Number	:	702-567-3495
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/18/2011
Last Update Date	:	01/22/2026

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