MEDICARE: MRS. LISA STANEK VANDER WEERD RD

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	1039462	KY

General Provider Information

NPI Number	:	1649872979
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LISA STANEK VANDER WEERD RD

Provider Business Mailing Address
First Line	:	2034 S XENIA WAY
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80231-3361
Country	:	US
Telephone Number	:	608-320-5472
Fax Number	:

Provider Business Practice Location Address
First Line	:	2034 S XENIA WAY
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80231-3361
Country	:	US
Telephone Number	:	608-320-5472
Fax Number	:

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

Provider Enumeration Date	:	11/11/2020
Last Update Date	:	11/11/2020

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