Provider Demographics
NPI:1912363219
Name:LIAS, JUANITA
Entity Type:Individual
Prefix:
First Name:JUANITA
Middle Name:
Last Name:LIAS
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:PO BOX 24894
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33802-4894
Mailing Address - Country:US
Mailing Address - Phone:863-688-9492
Mailing Address - Fax:
Practice Address - Street 1:1209 GOLCONDA RD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33801-2121
Practice Address - Country:US
Practice Address - Phone:863-688-9492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education