Provider Demographics
NPI:1255581849
Name:CONNACHER, LISA N (RD, CDE)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:N
Last Name:CONNACHER
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:925 E MCDOWELL RD
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2502
Mailing Address - Country:US
Mailing Address - Phone:602-239-4777
Mailing Address - Fax:
Practice Address - Street 1:925 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2502
Practice Address - Country:US
Practice Address - Phone:602-239-4777
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-19
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
13604133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
Z124970Medicare PIN