Provider Demographics
NPI:1922307040
Name:MATT, LISA ANN (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:MATT
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 TARENTUM BRIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:NEW KENSINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15068
Mailing Address - Country:US
Mailing Address - Phone:724-339-4940
Mailing Address - Fax:
Practice Address - Street 1:200 TARENTUM BRIDGE ROAD
Practice Address - Street 2:
Practice Address - City:NEW KENSINGTON
Practice Address - State:PA
Practice Address - Zip Code:15068
Practice Address - Country:US
Practice Address - Phone:724-339-4940
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN003901133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic