Provider Demographics
NPI:1235593732
Name:KLISMITH, ELIZABETH M (RD, CD)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:M
Last Name:KLISMITH
Suffix:
Gender:F
Credentials:RD, CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2630 FAIRFIELD PL
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53704-4825
Mailing Address - Country:US
Mailing Address - Phone:608-520-2575
Mailing Address - Fax:
Practice Address - Street 1:2500 OVERLOOK TER
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53705-2254
Practice Address - Country:US
Practice Address - Phone:608-256-1901
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2016-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
86063520OtherCOMMISSION ON DIETETIC REGISTATION
WI2902-29OtherDEPARTMENT OF SAFETY AND PROFESSIONAL SERVICES