Provider Demographics
NPI:1558589911
Name:TARTAMELLA KIMMEL, LISA (MS, RD, CD-N)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:TARTAMELLA KIMMEL
Suffix:
Gender:F
Credentials:MS, RD, CD-N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CENTENNIAL DR
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06461-1678
Mailing Address - Country:US
Mailing Address - Phone:203-878-6493
Mailing Address - Fax:
Practice Address - Street 1:20 YORK ST
Practice Address - Street 2:NUTRITION CLINIC- CBB52
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06510-3220
Practice Address - Country:US
Practice Address - Phone:203-688-2264
Practice Address - Fax:203-688-2141
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000101133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02658Medicare ID - Type UnspecifiedYNHH MEDICARE NUMBER