Healthcare Provider Details

I. General information

NPI: 1356560700
Provider Name (Legal Business Name): LISA LEE HANSON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13111 N PORT WASHINGTON RD
MEQUON WI
53097-2416
US

IV. Provider business mailing address

406 CRESCENT LN
THIENSVILLE WI
53092-1347
US

V. Phone/Fax

Practice location:
  • Phone: 262-243-7376
  • Fax:
Mailing address:
  • Phone: 262-238-0359
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number725446
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: