Provider Demographics
NPI:1871930677
Name:BURNETT, LISA RENEE (RD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:BURNETT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:GRUBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:442 WALTERS RD
Mailing Address - Street 2:
Mailing Address - City:CHAGRIN FALLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-2930
Mailing Address - Country:US
Mailing Address - Phone:269-806-7996
Mailing Address - Fax:
Practice Address - Street 1:9500 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:216-444-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2013-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH7223133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered