Provider Demographics
NPI:1932388212
Name:LOCKLEAR, LIZA JO (RD CD CDE)
Entity Type:Individual
Prefix:MRS
First Name:LIZA
Middle Name:JO
Last Name:LOCKLEAR
Suffix:
Gender:F
Credentials:RD CD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 22487
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54305-2487
Mailing Address - Country:US
Mailing Address - Phone:920-445-7222
Mailing Address - Fax:920-445-7289
Practice Address - Street 1:2641 DEVELOPMENT DR
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-4240
Practice Address - Country:US
Practice Address - Phone:920-338-6868
Practice Address - Fax:920-338-6869
Is Sole Proprietor?:No
Enumeration Date:2007-11-02
Last Update Date:2021-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI1610-29133V00000X
WI886243133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
886243OtherCOMMISSION ON DIETETIC REGISTRATION
21900466OtherNATIONAL CERTIFICATION BOARD FOR DIABETES