Provider Demographics
NPI:1447278643
Name:LIS, JESSIE SHERRY (RD,CDN)
Entity type:Individual
Prefix:MRS
First Name:JESSIE
Middle Name:SHERRY
Last Name:LIS
Suffix:
Gender:F
Credentials:RD,CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1394 VANDERBILT AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH TONAWANDA
Mailing Address - State:NY
Mailing Address - Zip Code:14120-2315
Mailing Address - Country:US
Mailing Address - Phone:716-834-9200
Mailing Address - Fax:716-862-6374
Practice Address - Street 1:3495 BAILEY AVE
Practice Address - Street 2:NUTRITION AND FOOD DEPT.
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215-1129
Practice Address - Country:US
Practice Address - Phone:716-834-9200
Practice Address - Fax:716-862-6374
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY544851133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered