Provider Demographics
NPI:1104411156
Name:MCMILLIAN, LACEY RENETTE
Entity type:Individual
Prefix:
First Name:LACEY
Middle Name:RENETTE
Last Name:MCMILLIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LACEY
Other - Middle Name:
Other - Last Name:SUMMERVILLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:111 LAUREL OAK DR
Mailing Address - Street 2:
Mailing Address - City:RED OAK
Mailing Address - State:TX
Mailing Address - Zip Code:75154-4634
Mailing Address - Country:US
Mailing Address - Phone:469-464-8912
Mailing Address - Fax:
Practice Address - Street 1:111 LAUREL OAK DR
Practice Address - Street 2:
Practice Address - City:RED OAK
Practice Address - State:TX
Practice Address - Zip Code:75154-4634
Practice Address - Country:US
Practice Address - Phone:469-464-8912
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-02
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS86032981133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal