MEDICARE: HAILEY NICOLE LACY MS, RD, LD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133VN1501X	Sports Dietetics Nutrition Registered Dietitian	164.009015	IL

General Provider Information

NPI Number	:	1932807849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HAILEY NICOLE LACY MS, RD, LD

Provider Business Mailing Address
First Line	:	1140 N WELLS ST UNIT 519
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60610-2529
Country	:	US
Telephone Number	:	812-987-3779
Fax Number	:

Provider Business Practice Location Address
First Line	:	2323 N SHEFFIELD AVE
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60614-3290
Country	:	US
Telephone Number	:	812-987-3779
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/20/2023
Last Update Date	:	02/20/2023

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