Provider Demographics
NPI:1124154851
Name:FENN, LISA ANN (MS RD LD)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:ANN
Last Name:FENN
Suffix:
Gender:F
Credentials:MS RD LD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:NICKLOW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS RD LD
Mailing Address - Street 1:222 TONGASS DRIVE
Mailing Address - Street 2:SEARHC
Mailing Address - City:SITKA
Mailing Address - State:AK
Mailing Address - Zip Code:99835
Mailing Address - Country:US
Mailing Address - Phone:907-966-2411
Mailing Address - Fax:907-966-8300
Practice Address - Street 1:3245 HOSPITAL DR
Practice Address - Street 2:SEARHC
Practice Address - City:JUNEAU
Practice Address - State:AK
Practice Address - Zip Code:99801-7809
Practice Address - Country:US
Practice Address - Phone:907-463-4040
Practice Address - Fax:907-463-4673
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK108133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKDT2342Medicaid
AKQ17468Medicare UPIN
AK8EA690Medicare ID - Type Unspecified