Healthcare Provider Details

I. General information

NPI: 1639166390
Provider Name (Legal Business Name): LISA M COLEMAN RD LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/28/2005
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2710 SAINT FRANCIS DR SUITE 510
WATERLOO IA
50702-5619
US

IV. Provider business mailing address

2710 SAINT FRANCIS DR SUITE 510
WATERLOO IA
50702-5619
US

V. Phone/Fax

Practice location:
  • Phone: 319-272-5358
  • Fax: 319-272-5445
Mailing address:
  • Phone: 319-272-5358
  • Fax: 319-272-5445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number01585
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: