Provider Demographics
NPI:1154597623
Name:DE FAZIO, LISA (RD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DE FAZIO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:DE FAZIO-GAMITYAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MS, RD
Mailing Address - Street 1:415 ROLLING OAKS DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91361-1029
Mailing Address - Country:US
Mailing Address - Phone:805-299-0301
Mailing Address - Fax:
Practice Address - Street 1:415 ROLLING OAKS DR
Practice Address - Street 2:SUITE 210
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91361-1029
Practice Address - Country:US
Practice Address - Phone:805-299-0301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-05
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA859439133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA859439OtherDIETETIC REGISTRATION