Provider Demographics
NPI:1750859286
Name:KEOVONGSA, LISA MARIE (RD, LDN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:KEOVONGSA
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 STANDISH RD
Mailing Address - Street 2:
Mailing Address - City:ARLINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02476-7069
Mailing Address - Country:US
Mailing Address - Phone:781-430-9833
Mailing Address - Fax:
Practice Address - Street 1:30 STANDISH RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:MA
Practice Address - Zip Code:02476-7069
Practice Address - Country:US
Practice Address - Phone:781-430-9833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4706133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered