Provider Demographics
NPI:1003478785
Name:TUCKER-WILLIAMS, LISA M (RD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:TUCKER-WILLIAMS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RD
Mailing Address - Street 1:7070 MILTON CT
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32583-5448
Mailing Address - Country:US
Mailing Address - Phone:850-698-8706
Mailing Address - Fax:
Practice Address - Street 1:7070 MILTON CT
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32583-5448
Practice Address - Country:US
Practice Address - Phone:850-698-8706
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-02
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3011133V00000X
FLND9168133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered