Provider Demographics
NPI:1194825695
Name:REISNER, LISA DAWN (RD)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:DAWN
Last Name:REISNER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:DAWN
Other - Last Name:FIELDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1869 BRENTWOOD ROAD
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:NY
Mailing Address - Zip Code:11717
Mailing Address - Country:US
Mailing Address - Phone:631-853-3400
Mailing Address - Fax:
Practice Address - Street 1:1869 BRENTWOOD ROAD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:NY
Practice Address - Zip Code:11717
Practice Address - Country:US
Practice Address - Phone:631-853-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-24
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005739133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered