Provider Demographics
NPI:1699292433
Name:BACON, LISA ANNE (RDN)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANNE
Last Name:BACON
Suffix:
Gender:F
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10624 CORONET CT
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:NC
Mailing Address - Zip Code:28075-8610
Mailing Address - Country:US
Mailing Address - Phone:919-440-0424
Mailing Address - Fax:
Practice Address - Street 1:1224 W ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28110-2820
Practice Address - Country:US
Practice Address - Phone:704-296-4891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-23
Last Update Date:2017-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL004760133V00000X, 133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist