Provider Demographics
NPI:1649564881
Name:TAYLOR, LISA ANN (LD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:LD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:LACHMUND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LD
Mailing Address - Street 1:527 W 3RD ST
Mailing Address - Street 2:
Mailing Address - City:KONAWA
Mailing Address - State:OK
Mailing Address - Zip Code:74849-1415
Mailing Address - Country:US
Mailing Address - Phone:580-925-3286
Mailing Address - Fax:
Practice Address - Street 1:527 W 3RD ST
Practice Address - Street 2:
Practice Address - City:KONAWA
Practice Address - State:OK
Practice Address - Zip Code:74849-1415
Practice Address - Country:US
Practice Address - Phone:580-925-3286
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-06
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1737133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered