Healthcare Provider Details

I. General information

NPI: 1366719312
Provider Name (Legal Business Name): LACY MAQUEL PUTTUCK R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2011
Last Update Date: 02/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6445 S TENAYA WAY STE 160
LAS VEGAS NV
89113-1991
US

IV. Provider business mailing address

6445 S TENAYA WAY STE 160
LAS VEGAS NV
89113-1991
US

V. Phone/Fax

Practice location:
  • Phone: 702-567-3495
  • Fax:
Mailing address:
  • Phone: 702-567-3495
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: