Provider Demographics
NPI:1689784290
Name:GRUDZIELANEK, LISA A (MS,RD,CD, CDE)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:GRUDZIELANEK
Suffix:
Gender:F
Credentials:MS,RD,CD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1760 WOODLAND WAY
Mailing Address - Street 2:
Mailing Address - City:SLINGER
Mailing Address - State:WI
Mailing Address - Zip Code:53086-9059
Mailing Address - Country:US
Mailing Address - Phone:414-732-4962
Mailing Address - Fax:262-794-3146
Practice Address - Street 1:16535 W BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5936
Practice Address - Country:US
Practice Address - Phone:414-732-4962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2013-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1731-029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI73840-0266Medicare ID - Type Unspecified
WIQ41454Medicare UPIN