Provider Demographics
NPI:1942242383
Name:MCCLINTOCK, LISA MARIE (RD)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARIE
Last Name:MCCLINTOCK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MISS
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:GEIHL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1839 DE SMET AVE
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:WY
Mailing Address - Zip Code:82801-5919
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1898 FORT RD
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:WY
Practice Address - Zip Code:82801-8320
Practice Address - Country:US
Practice Address - Phone:307-672-3473
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
916725133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered