Healthcare Provider Details

I. General information

NPI: 1932568201
Provider Name (Legal Business Name): LISA ROCHE RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2016
Last Update Date: 11/17/2021
Certification Date: 11/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1700 W PARADISE DR
WEST BEND WI
53095-9795
US

IV. Provider business mailing address

9200 W WISCONSIN AVE
MILWAUKEE WI
53226-3522
US

V. Phone/Fax

Practice location:
  • Phone: 262-334-3451
  • Fax:
Mailing address:
  • Phone: 414-805-6550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number810-29
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: