Provider Demographics
NPI:1861866006
Name:REILY, LISA M
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:REILY
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:MORROW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LD, CNSC
Mailing Address - Street 1:2401 KINGSLEY LN
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73128-4924
Mailing Address - Country:US
Mailing Address - Phone:405-923-9356
Mailing Address - Fax:
Practice Address - Street 1:2825 PARKLAWN DR
Practice Address - Street 2:
Practice Address - City:MIDWEST CITY
Practice Address - State:OK
Practice Address - Zip Code:73110-4201
Practice Address - Country:US
Practice Address - Phone:405-610-8728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-11-28
Last Update Date:2015-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1182133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered