Healthcare Provider Details

I. General information

NPI: 1982921755
Provider Name (Legal Business Name): LACY SPRAGUE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 05/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HIGH SERVICE AVE
NORTH PROVIDENCE RI
02904-5113
US

IV. Provider business mailing address

200 HIGH SERVICE AVE
NORTH PROVIDENCE RI
02904-5113
US

V. Phone/Fax

Practice location:
  • Phone: 401-456-3198
  • Fax:
Mailing address:
  • Phone: 508-765-9771
  • Fax: 508-764-2460

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2988
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: