Provider Demographics
NPI:1497037980
Name:LAURA, LISA M (RD, LDN, JD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:LAURA
Suffix:
Gender:F
Credentials:RD, LDN, JD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 GREENWOOD AVE
Mailing Address - Street 2:SUITE 410
Mailing Address - City:JENKINTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19046-2627
Mailing Address - Country:US
Mailing Address - Phone:267-240-4260
Mailing Address - Fax:
Practice Address - Street 1:101 GREENWOOD AVE
Practice Address - Street 2:SUITE 410
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-2627
Practice Address - Country:US
Practice Address - Phone:267-240-4260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-12
Last Update Date:2011-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004576133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered