Provider Demographics
NPI:1952719627
Name:BAKER, LISA (RDN, LDN, IBCLC)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BAKER
Suffix:
Gender:F
Credentials:RDN, LDN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 WILDWOOD DR
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29730-8974
Mailing Address - Country:US
Mailing Address - Phone:803-909-7300
Mailing Address - Fax:803-909-7397
Practice Address - Street 1:1070 HECKLE BLVD
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2853
Practice Address - Country:US
Practice Address - Phone:803-909-7300
Practice Address - Fax:803-909-7397
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-25
Last Update Date:2014-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC388133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered