Healthcare Provider Details

I. General information

NPI: 1851856041
Provider Name (Legal Business Name): LISA VANATTA MS, RDN, CSP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2019
Last Update Date: 07/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1919 E THOMAS RD BLDG 3
PHOENIX AZ
85016-7710
US

IV. Provider business mailing address

3200 E CAMELBACK RD STE 250
PHOENIX AZ
85018-2327
US

V. Phone/Fax

Practice location:
  • Phone: 602-933-0970
  • Fax: 602-933-4253
Mailing address:
  • Phone: 602-933-1813
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133VN1004X
TaxonomyPediatric Nutrition Registered Dietitian
License Number718221
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: