Healthcare Provider Details

I. General information

NPI: 1942989389
Provider Name (Legal Business Name): LISA SPROUSE MS, RDN, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA VALDESPINO

II. Dates (important events)

Enumeration Date: 07/13/2023
Last Update Date: 12/04/2023
Certification Date: 12/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4423 SADDLE SPUR
SAN ANTONIO TX
78253-4487
US

IV. Provider business mailing address

4423 SADDLE SPUR
SAN ANTONIO TX
78253-4487
US

V. Phone/Fax

Practice location:
  • Phone: 210-215-5653
  • Fax:
Mailing address:
  • Phone: 210-215-5653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDT06434
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License NumberDT06434
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: