Provider Demographics
NPI:1669591400
Name:STATNER, LISA M (RD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:STATNER
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5500 NEWCASTLE AVE
Mailing Address - Street 2:APT 55
Mailing Address - City:ENCINO
Mailing Address - State:CA
Mailing Address - Zip Code:91316-2133
Mailing Address - Country:US
Mailing Address - Phone:818-706-1114
Mailing Address - Fax:818-706-1177
Practice Address - Street 1:5500 NEWCASTLE AVE
Practice Address - Street 2:APT 55
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91316-2133
Practice Address - Country:US
Practice Address - Phone:805-377-3288
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-29
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAMNT811364Medicare ID - Type Unspecified