Provider Demographics
NPI:1851796049
Name:WELLNITZ, LISA DELAURENTIS (MS, RD, CNSC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DELAURENTIS
Last Name:WELLNITZ
Suffix:
Gender:F
Credentials:MS, RD, CNSC
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:DELAURENTIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2506 E FAIRMOUNT AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-1131
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1800 ORLEANS ST
Practice Address - Street 2:BLOOMBERG 9306
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0010
Practice Address - Country:US
Practice Address - Phone:410-955-5177
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-30
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDX3121133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered