Provider Demographics
NPI:1689291452
Name:DAVIS, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5155 CRYSTAL BROOK DR
Mailing Address - Street 2:
Mailing Address - City:MORRISTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:37814-1598
Mailing Address - Country:US
Mailing Address - Phone:847-361-3400
Mailing Address - Fax:
Practice Address - Street 1:2307 W ANDREW JOHNSON HWY STE 110
Practice Address - Street 2:
Practice Address - City:MORRISTOWN
Practice Address - State:TN
Practice Address - Zip Code:37814-3298
Practice Address - Country:US
Practice Address - Phone:423-254-0547
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-28
Last Update Date:2022-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1199133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered