Provider Demographics
NPI:1548417298
Name:EDEAL, LISA A (RD)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:A
Last Name:EDEAL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2200 H ST
Mailing Address - Street 2:PO BOX 277
Mailing Address - City:FAIRBURY
Mailing Address - State:NE
Mailing Address - Zip Code:68352-1119
Mailing Address - Country:US
Mailing Address - Phone:402-729-6846
Mailing Address - Fax:
Practice Address - Street 1:2200 H ST
Practice Address - Street 2:
Practice Address - City:FAIRBURY
Practice Address - State:NE
Practice Address - Zip Code:68352-1119
Practice Address - Country:US
Practice Address - Phone:402-729-6846
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-25
Last Update Date:2009-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE641133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE10025484200Medicaid
NE10025484200Medicaid