Provider Demographics
NPI:1184708463
Name:STOLLMAN, LISA BETH (MA, RD, CDE, CDN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:BETH
Last Name:STOLLMAN
Suffix:
Gender:F
Credentials:MA, RD, CDE, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 SEA COVE RD
Mailing Address - Street 2:
Mailing Address - City:NORTHPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11768-1850
Mailing Address - Country:US
Mailing Address - Phone:631-757-7406
Mailing Address - Fax:631-757-7406
Practice Address - Street 1:241 E MAIN ST
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:NY
Practice Address - Zip Code:11743-2924
Practice Address - Country:US
Practice Address - Phone:631-757-7406
Practice Address - Fax:631-757-7406
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001987-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYO3P421Medicare UPIN
NYO3P421Medicare ID - Type UnspecifiedREGISTERED DIETITIAN