Provider Demographics
NPI:1154410033
Name:BUNCE, LISA (RD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BUNCE
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 1:104 SEVENTY ACRE RD
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CT
Mailing Address - Zip Code:06896-2706
Mailing Address - Country:US
Mailing Address - Phone:203-938-0492
Mailing Address - Fax:
Practice Address - Street 1:104 SEVENTY ACRE RD
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CT
Practice Address - Zip Code:06896-2706
Practice Address - Country:US
Practice Address - Phone:203-938-0492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000195133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT270000195CT01OtherBCBS PROVIDER #
CT0013881OtherUS HEALTH CARE PROVIDER #
CT4488171OtherAETNA HEALTH PROVIDER #
CTP818135OtherOXFORD HEALTH PROVIDER #