Provider Demographics
NPI:1558459685
Name:RANDALL, LISA LYNN (RDN, LD, CDE)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LYNN
Last Name:RANDALL
Suffix:
Gender:F
Credentials:RDN, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 N RIVERPOINT BLVD
Mailing Address - Street 2:SUITE 245
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99202-1659
Mailing Address - Country:US
Mailing Address - Phone:509-209-2150
Mailing Address - Fax:509-232-8151
Practice Address - Street 1:501 N RIVERPOINT BLVD
Practice Address - Street 2:SUITE 245
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99202-1659
Practice Address - Country:US
Practice Address - Phone:509-209-2150
Practice Address - Fax:509-232-8151
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2016-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00001131133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7122724Medicaid
WA7122724Medicaid