Provider Demographics
NPI:1548834013
Name:DAVIS, LISA (RDN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5054 S 4600 W
Mailing Address - Street 2:
Mailing Address - City:MALAD CITY
Mailing Address - State:ID
Mailing Address - Zip Code:83252-6551
Mailing Address - Country:US
Mailing Address - Phone:719-290-8113
Mailing Address - Fax:
Practice Address - Street 1:5054 S 4600 W
Practice Address - Street 2:
Practice Address - City:MALAD CITY
Practice Address - State:ID
Practice Address - Zip Code:83252-6551
Practice Address - Country:US
Practice Address - Phone:719-290-8113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT12248913-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered