Provider Demographics
NPI:1336560895
Name:MOORE, LISA (RDN, LDN)
Entity Type:Individual
Prefix:MRS
First Name:LISA
Middle Name:
Last Name:MOORE
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:FAYE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RDN, LDN
Mailing Address - Street 1:3100 SHORE DR
Mailing Address - Street 2:
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23451-1199
Mailing Address - Country:US
Mailing Address - Phone:978-846-2275
Mailing Address - Fax:
Practice Address - Street 1:3100 SHORE DR
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23451-1467
Practice Address - Country:US
Practice Address - Phone:757-496-1671
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-30
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3578133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered