Provider Demographics
NPI:1992959654
Name:MILLER, LISA M (CD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:MILLER
Suffix:
Gender:F
Credentials:CD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:DIBOS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:240 MAPLE STREET
Mailing Address - Street 2:
Mailing Address - City:WOODRUFF
Mailing Address - State:WI
Mailing Address - Zip Code:54568
Mailing Address - Country:US
Mailing Address - Phone:715-356-8018
Mailing Address - Fax:715-356-8697
Practice Address - Street 1:240 MAPLE STREET
Practice Address - Street 2:
Practice Address - City:WOODRUFF
Practice Address - State:WI
Practice Address - Zip Code:54568
Practice Address - Country:US
Practice Address - Phone:715-356-8018
Practice Address - Fax:715-356-8697
Is Sole Proprietor?:No
Enumeration Date:2008-11-07
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2091-029133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered