Provider Demographics
NPI:1811383730
Name:MALONE, LISA JAYNE (RDN)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:JAYNE
Last Name:MALONE
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 2ND ST
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2205
Mailing Address - Country:US
Mailing Address - Phone:601-297-5099
Mailing Address - Fax:
Practice Address - Street 1:1117 2ND ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2205
Practice Address - Country:US
Practice Address - Phone:601-297-5099
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-07
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS133V00000X133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered