Healthcare Provider Details

I. General information

NPI: 1205440088
Provider Name (Legal Business Name): LISA SHARDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2020
Last Update Date: 08/31/2020
Certification Date: 08/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 E CHICAGO AVE
CHICAGO IL
60611-2991
US

IV. Provider business mailing address

3150 N LAKE SHORE DR APT 7A
CHICAGO IL
60657-4805
US

V. Phone/Fax

Practice location:
  • Phone: 312-227-4619
  • Fax:
Mailing address:
  • Phone: 312-882-1453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number164.003756
License Number StateIL
# 2
Primary TaxonomyN
Taxonomy Code174N00000X
TaxonomyLactation Consultant (Non-RN)
License NumberL-23455
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: