Provider Demographics
NPI:1659386514
Name:VANDER HART, LYSANDRA (RD)
Entity Type:Individual
Prefix:MRS
First Name:LYSANDRA
Middle Name:
Last Name:VANDER HART
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6941 CIMARRON DR SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546
Mailing Address - Country:US
Mailing Address - Phone:616-262-0617
Mailing Address - Fax:
Practice Address - Street 1:311 STATE STREET
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503
Practice Address - Country:US
Practice Address - Phone:616-249-0159
Practice Address - Fax:616-249-8688
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-29
Last Update Date:2015-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
945076133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered