Provider Demographics
NPI:1588674881
Name:BUSHMAN, LISA MARIE
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:MARIE
Last Name:BUSHMAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:71 VILLAGE GATE BLVD
Mailing Address - Street 2:
Mailing Address - City:DELAWARE
Mailing Address - State:OH
Mailing Address - Zip Code:43015
Mailing Address - Country:US
Mailing Address - Phone:614-580-0470
Mailing Address - Fax:
Practice Address - Street 1:629 N SANDUS KY AVE
Practice Address - Street 2:
Practice Address - City:BURYRUS
Practice Address - State:OH
Practice Address - Zip Code:44820
Practice Address - Country:US
Practice Address - Phone:419-562-4677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH10171133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered