Provider Demographics
NPI:1841615812
Name:RUDI-DAVIS, LISA (RDN, LDN)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:RUDI-DAVIS
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1835 S BROAD ST FL 1
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19148-2115
Mailing Address - Country:US
Mailing Address - Phone:215-834-9463
Mailing Address - Fax:
Practice Address - Street 1:1835 S BROAD ST FL 1
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-2115
Practice Address - Country:US
Practice Address - Phone:215-834-9463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-26
Last Update Date:2018-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN002162133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist