Provider Demographics
NPI:1962376061
Name:DEVINE, LISA M (RDN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:DEVINE
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 SEYMOUR ST STE 500
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06106-5524
Mailing Address - Country:US
Mailing Address - Phone:860-545-9440
Mailing Address - Fax:
Practice Address - Street 1:85 SEYMOUR ST STE 500
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5524
Practice Address - Country:US
Practice Address - Phone:860-545-9440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-01
Last Update Date:2025-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered