Provider Demographics
NPI:1275190555
Name:ALONSO, LISERIS (RDN,LND,LD)
Entity Type:Individual
Prefix:MRS
First Name:LISERIS
Middle Name:
Last Name:ALONSO
Suffix:
Gender:F
Credentials:RDN,LND,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4311 BAYOU BLVD APT 122
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-1953
Mailing Address - Country:US
Mailing Address - Phone:787-614-2850
Mailing Address - Fax:
Practice Address - Street 1:6002 BERRYHILL RD
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-5062
Practice Address - Country:US
Practice Address - Phone:850-626-5196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-22
Last Update Date:2019-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR86020039133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered