Provider Demographics
NPI:1588878409
Name:ANDRADE, LISA MELODY (LAC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MELODY
Last Name:ANDRADE
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24 S 600 E
Mailing Address - Street 2:STE. 2
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84102-1017
Mailing Address - Country:US
Mailing Address - Phone:801-521-0531
Mailing Address - Fax:801-521-2654
Practice Address - Street 1:24 S 600 E
Practice Address - Street 2:STE. 2
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84102-1017
Practice Address - Country:US
Practice Address - Phone:801-521-0531
Practice Address - Fax:801-521-2654
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6002853-1201171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist