Provider Demographics
NPI:1275286338
Name:VAN LEEUWEN, LISA (MS, RDN, LDN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:VAN LEEUWEN
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:STONEHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02180-1040
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:11 NORTH ST
Practice Address - Street 2:
Practice Address - City:STONEHAM
Practice Address - State:MA
Practice Address - Zip Code:02180-1040
Practice Address - Country:US
Practice Address - Phone:760-625-9708
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-30
Last Update Date:2024-06-14
Deactivation Date:2022-03-07
Deactivation Code:
Reactivation Date:2024-06-13
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered