Healthcare Provider Details

I. General information

NPI: 1932807849
Provider Name (Legal Business Name): HAILEY NICOLE LACY MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2023
Last Update Date: 02/20/2023
Certification Date: 02/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2323 N SHEFFIELD AVE
CHICAGO IL
60614-3290
US

IV. Provider business mailing address

1140 N WELLS ST UNIT 519
CHICAGO IL
60610-2529
US

V. Phone/Fax

Practice location:
  • Phone: 812-987-3779
  • Fax:
Mailing address:
  • Phone: 812-987-3779
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1501X
TaxonomySports Dietetics Nutrition Registered Dietitian
License Number164.009015
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: