MEDICARE: MS. LISA TUTTLE R.D.

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	262	WV

General Provider Information

NPI Number	:	1427328954
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LISA TUTTLE R.D.

Provider Business Mailing Address
First Line	:	1914 REDSTONE RD
Second Line	:
City	:	SOUTH CHARLESTON
State	:	WV
Zip	:	25309-9720
Country	:	US
Telephone Number	:	304-421-4405
Fax Number	:	304-345-5185

Provider Business Practice Location Address
First Line	:	1914 REDSTONE RD
Second Line	:
City	:	SOUTH CHARLESTON
State	:	WV
Zip	:	25309-9720
Country	:	US
Telephone Number	:	304-421-4405
Fax Number	:	304-345-5185

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

Provider Enumeration Date	:	12/30/2011
Last Update Date	:	12/30/2011

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