Provider Demographics
NPI:1710086277
Name:PETTER, LYSSA MERRIAM (MS,RD,LDN)
Entity Type:Individual
Prefix:
First Name:LYSSA
Middle Name:MERRIAM
Last Name:PETTER
Suffix:
Gender:F
Credentials:MS,RD,LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 PINECREST RD
Mailing Address - Street 2:
Mailing Address - City:ANDOVER
Mailing Address - State:MA
Mailing Address - Zip Code:01810-5712
Mailing Address - Country:US
Mailing Address - Phone:978-687-0156
Mailing Address - Fax:978-681-9075
Practice Address - Street 1:CARITAS HOLY FAMILY HOSPITAL 70 EAST STREET
Practice Address - Street 2:CONVENT BUILDING
Practice Address - City:METHUEN
Practice Address - State:MA
Practice Address - Zip Code:01844
Practice Address - Country:US
Practice Address - Phone:978-687-0156
Practice Address - Fax:978-681-9075
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA826133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA701743OtherCDR ID #
MA826OtherDIETITIAN LICENSE #
MA701743OtherCDR ID #