Provider Demographics
NPI:1417285313
Name:REDDAN, LISA PAIGE (MS RD CDE)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:PAIGE
Last Name:REDDAN
Suffix:
Gender:F
Credentials:MS RD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:703 S GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59715-5221
Mailing Address - Country:US
Mailing Address - Phone:406-582-0357
Mailing Address - Fax:406-582-5481
Practice Address - Street 1:703 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-5221
Practice Address - Country:US
Practice Address - Phone:406-582-0357
Practice Address - Fax:406-582-5481
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-03
Last Update Date:2009-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA670839133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered