Provider Demographics
NPI:1487000279
Name:KNOLL, LISA S (RD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:S
Last Name:KNOLL
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:S
Other - Last Name:SHAMBAUGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:409 S 2ND ST
Mailing Address - Street 2:2F
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:111 S FRONT ST
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17101-2010
Practice Address - Country:US
Practice Address - Phone:717-782-5283
Practice Address - Fax:717-782-5192
Is Sole Proprietor?:No
Enumeration Date:2016-05-11
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN000007133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103125389Medicaid
PA103125389Medicaid