Provider Demographics
NPI:1124468418
Name:MOONEY, LISSA GAYE (RD)
Entity type:Individual
Prefix:MRS
First Name:LISSA
Middle Name:GAYE
Last Name:MOONEY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6551 ELMO ST
Mailing Address - Street 2:
Mailing Address - City:TUJUNGA
Mailing Address - State:CA
Mailing Address - Zip Code:91042-2528
Mailing Address - Country:US
Mailing Address - Phone:818-219-1082
Mailing Address - Fax:
Practice Address - Street 1:6551 ELMO ST
Practice Address - Street 2:
Practice Address - City:TUJUNGA
Practice Address - State:CA
Practice Address - Zip Code:91042-2528
Practice Address - Country:US
Practice Address - Phone:818-219-1082
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2013-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA719965133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered