Provider Demographics
NPI:1063662161
Name:CARPENTER, LISA (RD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CARPENTER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:292 N LAKE CUNNINGHAM AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:FL
Mailing Address - Zip Code:32259-7969
Mailing Address - Country:US
Mailing Address - Phone:904-287-9574
Mailing Address - Fax:
Practice Address - Street 1:292 N LAKE CUNNINGHAM AVE
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:FL
Practice Address - Zip Code:32259-7969
Practice Address - Country:US
Practice Address - Phone:904-287-9574
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-25
Last Update Date:2019-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5086133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered