Provider Demographics
NPI:1205425964
Name:ACKERMAN, LISA (CN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ACKERMAN
Suffix:
Gender:F
Credentials:CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 298
Mailing Address - Street 2:
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-0298
Mailing Address - Country:US
Mailing Address - Phone:970-556-4409
Mailing Address - Fax:206-231-5086
Practice Address - Street 1:5401 LEARY AVE NW STE 202
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98107-4070
Practice Address - Country:US
Practice Address - Phone:206-297-6013
Practice Address - Fax:206-582-3472
Is Sole Proprietor?:No
Enumeration Date:2021-01-15
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61133436133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist