Provider Demographics
NPI:1184782278
Name:HAGAN, LISA MARIE (RD, LD)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:HAGAN
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 MONTEGO CT
Mailing Address - Street 2:
Mailing Address - City:VICTORIA
Mailing Address - State:TX
Mailing Address - Zip Code:77901-3724
Mailing Address - Country:US
Mailing Address - Phone:361-570-8355
Mailing Address - Fax:
Practice Address - Street 1:102 MONTEGO CT
Practice Address - Street 2:
Practice Address - City:VICTORIA
Practice Address - State:TX
Practice Address - Zip Code:77901-3724
Practice Address - Country:US
Practice Address - Phone:361-570-8355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX848468133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered