Healthcare Provider Details

I. General information

NPI: 1801588843
Provider Name (Legal Business Name): LISA ANN ANDERSON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA A GOODMAN

II. Dates (important events)

Enumeration Date: 05/25/2023
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

550 S LANDMARK AVE
BLOOMINGTON IN
47403-3239
US

IV. Provider business mailing address

250 N SHADELAND AVE
INDIANAPOLIS IN
46219-4959
US

V. Phone/Fax

Practice location:
  • Phone: 812-353-9239
  • Fax: 812-333-5978
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number37000625A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: