Provider Demographics
NPI:1710418561
Name:WEIGLE, LISA A (RD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:WEIGLE
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 HWY 50
Mailing Address - Street 2:
Mailing Address - City:STATELINE
Mailing Address - State:NV
Mailing Address - Zip Code:89449-0000
Mailing Address - Country:US
Mailing Address - Phone:775-586-5000
Mailing Address - Fax:775-586-5055
Practice Address - Street 1:15 HWY 50
Practice Address - Street 2:
Practice Address - City:STATELINE
Practice Address - State:NV
Practice Address - Zip Code:89449-0000
Practice Address - Country:US
Practice Address - Phone:775-586-5000
Practice Address - Fax:775-586-5055
Is Sole Proprietor?:No
Enumeration Date:2017-03-23
Last Update Date:2018-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV39472-DI-0133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered