Provider Demographics
NPI:1083911317
Name:WHEAT, LISA RENEE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:WHEAT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1208
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:KY
Mailing Address - Zip Code:40476-1208
Mailing Address - Country:US
Mailing Address - Phone:859-626-4502
Mailing Address - Fax:859-623-5910
Practice Address - Street 1:216 BOGGS LN
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:KY
Practice Address - Zip Code:40475-2522
Practice Address - Country:US
Practice Address - Phone:859-626-4502
Practice Address - Fax:859-623-5910
Is Sole Proprietor?:No
Enumeration Date:2011-02-23
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY0834133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered