Provider Demographics
NPI:1538542550
Name:EDEN, LISA M (RD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:EDEN
Suffix:
Gender:F
Credentials:RD
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 53
Mailing Address - Street 2:
Mailing Address - City:ARDEN
Mailing Address - State:NY
Mailing Address - Zip Code:10910-0053
Mailing Address - Country:US
Mailing Address - Phone:603-560-4907
Mailing Address - Fax:
Practice Address - Street 1:633 ROUTE 211 E STE 2
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10941-1781
Practice Address - Country:US
Practice Address - Phone:603-560-4907
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-08
Last Update Date:2023-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004863133V00000X
133V00000X
NY007631133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered