Provider Demographics
NPI:1750393500
Name:STITZLEIN, LISA M (RD/LD/MED)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:STITZLEIN
Suffix:
Gender:F
Credentials:RD/LD/MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2415 COUNTY ROAD 377
Mailing Address - Street 2:
Mailing Address - City:LOUDONVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44842-9302
Mailing Address - Country:US
Mailing Address - Phone:419-529-4602
Mailing Address - Fax:
Practice Address - Street 1:1456 PARK AVE W
Practice Address - Street 2:RM. 122
Practice Address - City:MANSFIELD
Practice Address - State:OH
Practice Address - Zip Code:44906-2700
Practice Address - Country:US
Practice Address - Phone:419-529-4602
Practice Address - Fax:419-529-4664
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.1970133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered