Provider Demographics
NPI:1093765257
Name:KOVALEK, LISA M
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:M
Last Name:KOVALEK
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 1:276 HORNSBY CT
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-8461
Mailing Address - Country:US
Mailing Address - Phone:919-833-2525
Mailing Address - Fax:
Practice Address - Street 1:105 BODIN CIR
Practice Address - Street 2:
Practice Address - City:TRAVIS AFB
Practice Address - State:CA
Practice Address - Zip Code:94535-1801
Practice Address - Country:US
Practice Address - Phone:916-833-2525
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2007-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered