Provider Demographics
NPI:1275130296
Name:LUEVANO, LISA NICOLE (MS, MPH, RD, CPH)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:NICOLE
Last Name:LUEVANO
Suffix:
Gender:F
Credentials:MS, MPH, RD, CPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 LAKE BLVD APT 165
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-2814
Mailing Address - Country:US
Mailing Address - Phone:510-691-0913
Mailing Address - Fax:
Practice Address - Street 1:510 LAKE BLVD
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-2854
Practice Address - Country:US
Practice Address - Phone:510-691-0913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-02
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86119043133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered