Provider Demographics
NPI:1306002191
Name:PELUSI, LISA M (RD,LD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:PELUSI
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3700 KOLBE RD.
Mailing Address - Street 2:
Mailing Address - City:LORAIN
Mailing Address - State:OH
Mailing Address - Zip Code:44053-1697
Mailing Address - Country:US
Mailing Address - Phone:440-960-3555
Mailing Address - Fax:440-960-3621
Practice Address - Street 1:3700 KOLBE RD.
Practice Address - Street 2:
Practice Address - City:LORAIN
Practice Address - State:OH
Practice Address - Zip Code:44053-1697
Practice Address - Country:US
Practice Address - Phone:440-960-3555
Practice Address - Fax:440-960-3621
Is Sole Proprietor?:No
Enumeration Date:2008-08-01
Last Update Date:2015-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH707050133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHMT72531Medicare PIN