Provider Demographics
NPI:1740456243
Name:FAUCON, LISA NICOLE (MS RD CNSC)
Entity type:Individual
Prefix:MISS
First Name:LISA
Middle Name:NICOLE
Last Name:FAUCON
Suffix:
Gender:F
Credentials:MS RD CNSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 PARNASSUS AVE
Mailing Address - Street 2:M-294
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2204
Mailing Address - Country:US
Mailing Address - Phone:415-353-8254
Mailing Address - Fax:415-353-8703
Practice Address - Street 1:505 PARNASSUS AVE
Practice Address - Street 2:M-294
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2204
Practice Address - Country:US
Practice Address - Phone:415-353-8254
Practice Address - Fax:415-353-8703
Is Sole Proprietor?:No
Enumeration Date:2008-05-05
Last Update Date:2014-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA954974133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA954974OtherCDR