Provider Demographics
NPI:1386079663
Name:DAVIDSON, LACY MICHELLE (RDN)
Entity type:Individual
Prefix:
First Name:LACY
Middle Name:MICHELLE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5170 US RT 60 EAST
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25705
Mailing Address - Country:US
Mailing Address - Phone:304-528-4600
Mailing Address - Fax:
Practice Address - Street 1:5170 US RT 60 EAST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25705
Practice Address - Country:US
Practice Address - Phone:304-528-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-05
Last Update Date:2014-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV934133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
P01249406OtherRAILROAD MEDICARE
P01249406OtherRAILROAD MEDICARE