Provider Demographics
NPI:1093172090
Name:SAMUELS, LISA BROOKE (RD)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:BROOKE
Last Name:SAMUELS
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 1:67 PROSPECT AVE
Mailing Address - Street 2:#12-C
Mailing Address - City:HEWLETT
Mailing Address - State:NY
Mailing Address - Zip Code:11557-1640
Mailing Address - Country:US
Mailing Address - Phone:516-993-3267
Mailing Address - Fax:516-239-5167
Practice Address - Street 1:67 PROSPECT AVE
Practice Address - Street 2:#12-C
Practice Address - City:HEWLETT
Practice Address - State:NY
Practice Address - Zip Code:11557-1640
Practice Address - Country:US
Practice Address - Phone:516-993-3267
Practice Address - Fax:516-239-5167
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-21
Last Update Date:2016-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86034080133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered