Healthcare Provider Details

I. General information

NPI: 1275600397
Provider Name (Legal Business Name): LISA MARIE MERRILL M.S.,R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 10/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3939 VAN HORN RD
TRENTON MI
48183-4013
US

IV. Provider business mailing address

3341 22ND ST
WYANDOTTE MI
48192-6012
US

V. Phone/Fax

Practice location:
  • Phone: 734-502-8264
  • Fax: 877-287-7216
Mailing address:
  • Phone: 734-502-8264
  • Fax: 734-362-7501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number804989
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: