Healthcare Provider Details

I. General information

NPI: 1083911317
Provider Name (Legal Business Name): LISA RENEE WHEAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2011
Last Update Date: 02/23/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

216 BOGGS LN
RICHMOND KY
40475-2522
US

IV. Provider business mailing address

PO BOX 1208
RICHMOND KY
40476-1208
US

V. Phone/Fax

Practice location:
  • Phone: 859-626-4502
  • Fax: 859-623-5910
Mailing address:
  • Phone: 859-626-4502
  • Fax: 859-623-5910

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number0834
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: