Provider Demographics
NPI:1639166390
Name:COLEMAN, LISA M (RD LD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:COLEMAN
Suffix:
Gender:F
Credentials:RD LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2710 SAINT FRANCIS DR
Mailing Address - Street 2:SUITE 510
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-5619
Mailing Address - Country:US
Mailing Address - Phone:319-272-5358
Mailing Address - Fax:319-272-5445
Practice Address - Street 1:2710 SAINT FRANCIS DR
Practice Address - Street 2:SUITE 510
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50702-5619
Practice Address - Country:US
Practice Address - Phone:319-272-5358
Practice Address - Fax:319-272-5445
Is Sole Proprietor?:No
Enumeration Date:2005-09-28
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA01585133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q08950Medicare UPIN
IAI11350Medicare PIN
451020176Medicare PIN
IAI0923249Medicare PIN