MEDICARE: LISA D ELLIS MS, RD, CDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	165-1	NY

General Provider Information

NPI Number	:	1265583629
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA D ELLIS MS, RD, CDN

Provider Business Mailing Address
First Line	:	1301 MAMARONECK AVE
Second Line	:
City	:	WHITE PLAINS
State	:	NY
Zip	:	10605-5202
Country	:	US
Telephone Number	:	914-589-7962
Fax Number	:	914-761-3963

Provider Business Practice Location Address
First Line	:	1301 MAMARONECK AVE
Second Line	:
City	:	WHITE PLAINS
State	:	NY
Zip	:	10605-5202
Country	:	US
Telephone Number	:	914-589-7962
Fax Number	:	914-761-3963

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/14/2007
Last Update Date	:	07/08/2007

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