MEDICARE: LISA KIM DEGUZMAN RD CDN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1013618842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA KIM DEGUZMAN RD CDN

Provider Business Mailing Address
First Line	:	38 MADISON CT
Second Line	:
City	:	WALLKILL
State	:	NY
Zip	:	12589-3006
Country	:	US
Telephone Number	:	845-527-5014
Fax Number	:

Provider Business Practice Location Address
First Line	:	38 MADISON CT
Second Line	:
City	:	WALLKILL
State	:	NY
Zip	:	12589-3006
Country	:	US
Telephone Number	:	845-527-5014
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/17/2023
Last Update Date	:	03/17/2023

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