Provider Demographics
NPI:1356753263
Name:WILLIAMS, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17832 RANCH DRIVE
Mailing Address - Street 2:UNIT 1
Mailing Address - City:YORBA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92886
Mailing Address - Country:US
Mailing Address - Phone:714-742-0687
Mailing Address - Fax:
Practice Address - Street 1:17832 RANCH DR
Practice Address - Street 2:UNIT 1
Practice Address - City:YORBA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92886-3351
Practice Address - Country:US
Practice Address - Phone:714-742-0687
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-27
Last Update Date:2014-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA965082133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered