Provider Demographics
NPI:1811207020
Name:WINGHART, LISA ANNE (MPA, RDN)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANNE
Last Name:WINGHART
Suffix:
Gender:F
Credentials:MPA, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 N 18TH AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85007-3232
Mailing Address - Country:US
Mailing Address - Phone:585-355-3265
Mailing Address - Fax:
Practice Address - Street 1:150 N 18TH AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85007-3232
Practice Address - Country:US
Practice Address - Phone:585-355-3265
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-21
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY007022133V00000X
NY00946879133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered