Provider Demographics
NPI:1659735215
Name:KOPECKY, LISA ANN (MS, RD, LN)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ANN
Last Name:KOPECKY
Suffix:
Gender:F
Credentials:MS, RD, LN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2905 3RD AVE SE
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:SD
Mailing Address - Zip Code:57401-5420
Mailing Address - Country:US
Mailing Address - Phone:605-626-4252
Mailing Address - Fax:605-626-4251
Practice Address - Street 1:2905 3RD AVE SE
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:SD
Practice Address - Zip Code:57401
Practice Address - Country:US
Practice Address - Phone:605-626-4252
Practice Address - Fax:605-626-4251
Is Sole Proprietor?:No
Enumeration Date:2016-04-11
Last Update Date:2016-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD0075133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered