Provider Demographics
NPI:1699163063
Name:DIEWALD, LISA KIESER (MS, RD)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:KIESER
Last Name:DIEWALD
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:ELLEN
Other - Last Name:KIESER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:118 CHRISTINE DR
Mailing Address - Street 2:
Mailing Address - City:DOWNINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19335-1518
Mailing Address - Country:US
Mailing Address - Phone:610-864-3430
Mailing Address - Fax:
Practice Address - Street 1:552 EXTON CMNS
Practice Address - Street 2:
Practice Address - City:EXTON
Practice Address - State:PA
Practice Address - Zip Code:19341-2452
Practice Address - Country:US
Practice Address - Phone:610-347-2045
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN002683133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered