MEDICARE: LISA M STITZLEIN R.D./L.D./M.ED.

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	LD.1970	OH

General Provider Information

NPI Number	:	1750393500
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA M STITZLEIN R.D./L.D./M.ED.

Provider Business Mailing Address
First Line	:	2415 COUNTY ROAD 377
Second Line	:
City	:	LOUDONVILLE
State	:	OH
Zip	:	44842-9302
Country	:	US
Telephone Number	:	419-529-4602
Fax Number	:

Provider Business Practice Location Address
First Line	:	1456 PARK AVE W
Second Line	:	RM. 122
City	:	MANSFIELD
State	:	OH
Zip	:	44906-2700
Country	:	US
Telephone Number	:	419-529-4602
Fax Number	:	419-529-4664

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

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	07/08/2007

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