Healthcare Provider Details

I. General information

NPI: 1467852889
Provider Name (Legal Business Name): LISA ANNE YARAH RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA ANNE PETROCCI

II. Dates (important events)

Enumeration Date: 09/04/2014
Last Update Date: 10/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

321 GIFFORD ST
SYRACUSE NY
13204-3201
US

IV. Provider business mailing address

321 GIFFORD ST
SYRACUSE NY
13204-3201
US

V. Phone/Fax

Practice location:
  • Phone: 315-703-2600
  • Fax: 315-703-2621
Mailing address:
  • Phone: 315-703-2600
  • Fax: 315-703-2621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number005342
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number005342-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: