Healthcare Provider Details

I. General information

NPI: 1053600957
Provider Name (Legal Business Name): LISA STEWART MINK R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2011
Last Update Date: 02/14/2020
Certification Date: 02/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1925 W. MOUNTAIN VIEW AVE
LONGMONT CO
80501
US

IV. Provider business mailing address

1925 MOUNTAIN VIEW AVE
LONGMONT CO
80501-3128
US

V. Phone/Fax

Practice location:
  • Phone: 720-494-3119
  • Fax:
Mailing address:
  • Phone: 303-485-4198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number717690
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number717690
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: