Provider Demographics
NPI:1073232112
Name:TARLETON, LISA MEDI (BS-NDTR)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MEDI
Last Name:TARLETON
Suffix:
Gender:F
Credentials:BS-NDTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10813 PEBBLE HILL DR
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89521-8330
Mailing Address - Country:US
Mailing Address - Phone:775-250-0453
Mailing Address - Fax:
Practice Address - Street 1:9476 DOUBLE R BLVD STE A
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89521-2959
Practice Address - Country:US
Practice Address - Phone:775-284-3333
Practice Address - Fax:775-284-3395
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-23
Last Update Date:2022-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV86038139136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, RegisteredGroup - Single Specialty