Provider Demographics
NPI:1043698186
Name:WILLIAMS, LISA ELLEN (RD)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:ELLEN
Last Name:WILLIAMS
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1311 W TOWNLEY AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85021-4408
Mailing Address - Country:US
Mailing Address - Phone:602-465-3634
Mailing Address - Fax:
Practice Address - Street 1:1311 W TOWNLEY AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85021-4408
Practice Address - Country:US
Practice Address - Phone:602-465-3634
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-08
Last Update Date:2015-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ831503133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered