Provider Demographics
NPI:1679092183
Name:HENDERSON, LISA (RDN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HENDERSON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7811 NE 156TH ST
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:WA
Mailing Address - Zip Code:98028-4626
Mailing Address - Country:US
Mailing Address - Phone:206-579-0207
Mailing Address - Fax:
Practice Address - Street 1:3925 159TH AVE NE
Practice Address - Street 2:
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-6309
Practice Address - Country:US
Practice Address - Phone:408-665-3726
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-15
Last Update Date:2017-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60795450133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered