Provider Demographics
NPI:1033497425
Name:WADDELL, LACEY (MS, RD, LD)
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:
Last Name:WADDELL
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:
Other - Last Name:BURRELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS, RD, LN
Mailing Address - Street 1:PO BOX 517
Mailing Address - Street 2:
Mailing Address - City:SUNDANCE
Mailing Address - State:WY
Mailing Address - Zip Code:82729-0517
Mailing Address - Country:US
Mailing Address - Phone:307-283-3501
Mailing Address - Fax:
Practice Address - Street 1:713 W OAK STREET
Practice Address - Street 2:
Practice Address - City:SUNDANCE
Practice Address - State:WY
Practice Address - Zip Code:82729
Practice Address - Country:US
Practice Address - Phone:307-283-3501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-02
Last Update Date:2018-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0410133V00000X
WY211133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered