Provider Demographics
NPI:1013618842
Name:DEGUZMAN, LISA KIM (RD CDN)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:KIM
Last Name:DEGUZMAN
Suffix:
Gender:F
Credentials:RD CDN
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:KIM
Other - Last Name:REVITZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:38 MADISON CT
Mailing Address - Street 2:
Mailing Address - City:WALLKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12589-3006
Mailing Address - Country:US
Mailing Address - Phone:845-527-5014
Mailing Address - Fax:
Practice Address - Street 1:38 MADISON CT
Practice Address - Street 2:
Practice Address - City:WALLKILL
Practice Address - State:NY
Practice Address - Zip Code:12589-3006
Practice Address - Country:US
Practice Address - Phone:845-527-5014
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-17
Last Update Date:2023-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered