Provider Demographics
NPI:1649872979
Name:VANDER WEERD, LISA STANEK (RD)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:STANEK
Last Name:VANDER WEERD
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:STANEK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:2034 S XENIA WAY
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80231-3361
Mailing Address - Country:US
Mailing Address - Phone:608-320-5472
Mailing Address - Fax:
Practice Address - Street 1:2034 S XENIA WAY
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80231-3361
Practice Address - Country:US
Practice Address - Phone:608-320-5472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-11
Last Update Date:2020-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1039462133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered