Basic Information
| Provider Information | |||||||||
| NPI: | 1770966905 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BAKER | ||||||||
| FirstName: | LACEY | ||||||||
| MiddleName: | ANDERSON | ||||||||
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| Credential: | RD, CSP, LD, CNSC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1289 | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336011289 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138448927 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5 TAMPA GENERAL CIR | ||||||||
| Address2: | |||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336063601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8138447473 | ||||||||
| FaxNumber: | 8138441966 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/07/2015 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 7706 | OH | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.