Provider Demographics
NPI:1164743126
Name:SUPPLEE-PULLIAM, LISA MICHELLE (RD, LD)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:MICHELLE
Last Name:SUPPLEE-PULLIAM
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:299 KINGS DAUGHTERS DR
Mailing Address - Street 2:FRMC
Mailing Address - City:FRANKFORT
Mailing Address - State:KY
Mailing Address - Zip Code:40601-6514
Mailing Address - Country:US
Mailing Address - Phone:502-226-7839
Mailing Address - Fax:502-226-7936
Practice Address - Street 1:299 KINGS DAUGHTERS DR
Practice Address - Street 2:FRMC
Practice Address - City:FRANKFORT
Practice Address - State:KY
Practice Address - Zip Code:40601-6514
Practice Address - Country:US
Practice Address - Phone:502-226-7839
Practice Address - Fax:502-226-7936
Is Sole Proprietor?:No
Enumeration Date:2010-06-14
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-1792133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered