Provider Demographics
NPI:1215414438
Name:HYATT, LISA
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:HYATT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 MAIN ST OFC 202
Mailing Address - Street 2:
Mailing Address - City:OLD SAYBROOK
Mailing Address - State:CT
Mailing Address - Zip Code:06475-2332
Mailing Address - Country:US
Mailing Address - Phone:860-941-7251
Mailing Address - Fax:
Practice Address - Street 1:247 MAIN ST OFC 202
Practice Address - Street 2:
Practice Address - City:OLD SAYBROOK
Practice Address - State:CT
Practice Address - Zip Code:06475-2332
Practice Address - Country:US
Practice Address - Phone:860-941-7251
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1642133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist