Healthcare Provider Details

I. General information

NPI: 1679813489
Provider Name (Legal Business Name): LISA ANN HARDY R.D. L.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2013
Last Update Date: 03/13/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3910 WASHINGTON PKWY
IDAHO FALLS ID
83404-7596
US

IV. Provider business mailing address

3910 WASHINGTON PKWY
IDAHO FALLS ID
83404-7596
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-1122
  • Fax: 208-523-2582
Mailing address:
  • Phone: 208-523-1122
  • Fax: 208-523-2582

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberD-745
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: