Provider Demographics
NPI:1275691065
Name:WRIGHT, LISA C (RDLD)
Entity Type:Individual
Prefix:MS
First Name:LISA
Middle Name:C
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:RDLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 BONAVENTURE RD
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-3033
Mailing Address - Country:US
Mailing Address - Phone:912-232-0295
Mailing Address - Fax:
Practice Address - Street 1:2 WHEELER ST
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-5700
Practice Address - Country:US
Practice Address - Phone:912-356-2953
Practice Address - Fax:912-356-2465
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD002039133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10053604OtherAMERIGROUP PROVIDER NUMBE