Provider Demographics
NPI:1659606028
Name:LAWRENCE, LISE D (RD)
Entity Type:Individual
Prefix:MS
First Name:LISE
Middle Name:D
Last Name:LAWRENCE
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 1:62 LANTERN HL
Mailing Address - Street 2:
Mailing Address - City:NEWINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06111-3413
Mailing Address - Country:US
Mailing Address - Phone:860-667-9477
Mailing Address - Fax:
Practice Address - Street 1:41 BREWSTER ROAD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06011
Practice Address - Country:US
Practice Address - Phone:860-585-3911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-10-02
Last Update Date:2009-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000753133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered