Provider Demographics
NPI:1538344106
Name:DOUGLASS, LISA MARIE (RD/LD)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:DOUGLASS
Suffix:
Gender:F
Credentials:RD/LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 N 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DENNISON
Mailing Address - State:OH
Mailing Address - Zip Code:44621-1003
Mailing Address - Country:US
Mailing Address - Phone:740-922-2800
Mailing Address - Fax:740-922-7483
Practice Address - Street 1:819 N 1ST ST
Practice Address - Street 2:
Practice Address - City:DENNISON
Practice Address - State:OH
Practice Address - Zip Code:44621-1003
Practice Address - Country:US
Practice Address - Phone:740-922-2800
Practice Address - Fax:740-922-7483
Is Sole Proprietor?:No
Enumeration Date:2008-01-02
Last Update Date:2008-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH5131133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH065500Medicare PIN