Healthcare Provider Details

I. General information

NPI: 1831388636
Provider Name (Legal Business Name): STACEY MARIE LAMB RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: STACEY MARIE LAVOIE RD

II. Dates (important events)

Enumeration Date: 10/17/2007
Last Update Date: 06/04/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3181 SW SAM JACKSON PARK RD
PORTLAND OR
97239-3011
US

IV. Provider business mailing address

PO BOX 574 MAIL CODE: CDRC-F
PORTLAND OR
97207-0574
US

V. Phone/Fax

Practice location:
  • Phone: 503-418-2213
  • Fax:
Mailing address:
  • Phone: 503-418-2213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number841
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number234
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: