Healthcare Provider Details

I. General information

NPI: 1033497425
Provider Name (Legal Business Name): LACEY WADDELL MS, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LACEY BURRELL MS, RD, LN

II. Dates (important events)

Enumeration Date: 08/02/2011
Last Update Date: 12/20/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

713 W OAK STREET
SUNDANCE WY
82729
US

IV. Provider business mailing address

PO BOX 517
SUNDANCE WY
82729-0517
US

V. Phone/Fax

Practice location:
  • Phone: 307-283-3501
  • Fax:
Mailing address:
  • Phone: 307-283-3501
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number0410
License Number StateSD
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number211
License Number StateWY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: