Provider Demographics
NPI:1821455940
Name:EBERLY, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:EBERLY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2121 6TH AVE
Mailing Address - Street 2:N1103
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98121-2933
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2121 6TH AVE
Practice Address - Street 2:N1103
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98121-2933
Practice Address - Country:US
Practice Address - Phone:202-430-6126
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA86046825133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered