Provider Demographics
NPI:1184431652
Name:CORNEJO, LISSETTE (MS, RD, CSSD)
Entity type:Individual
Prefix:
First Name:LISSETTE
Middle Name:
Last Name:CORNEJO
Suffix:
Gender:F
Credentials:MS, RD, CSSD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8400 DELMAR BLVD APT 523
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63124-2344
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8400 DELMAR BLVD APT 523
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63124-2344
Practice Address - Country:US
Practice Address - Phone:407-716-3006
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-17
Last Update Date:2024-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1501XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Sports Dietetics