Provider Demographics
NPI:1306902622
Name:LUCAS, DONNA M (RD,LD)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:M
Last Name:LUCAS
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 N. BEAVER
Mailing Address - Street 2:PAYER CREDENTIALING
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86004
Mailing Address - Country:US
Mailing Address - Phone:928-213-6235
Mailing Address - Fax:928-213-6292
Practice Address - Street 1:269 S CANDY LN
Practice Address - Street 2:
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4158
Practice Address - Country:US
Practice Address - Phone:928-639-6543
Practice Address - Fax:928-639-6340
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-29
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1142133V00000X
AZ614026133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ198112Medicare PIN
AZZ198593Medicare PIN
OHMT01965Medicare PIN
OHMT01964Medicare UPIN