Basic Information
| Provider Information | |||||||||
| NPI: | 1124339072 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WRIGHT | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MS, RD, LDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10400 SOUTHWEST HWY | ||||||||
| Address2: | LOWER LEVEL | ||||||||
| City: | CHICAGO RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604151367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085817308 | ||||||||
| FaxNumber: | 7085817309 | ||||||||
| Practice Location | |||||||||
| Address1: | 10400 SOUTHWEST HWY | ||||||||
| Address2: | LOWER LEVEL | ||||||||
| City: | CHICAGO RIDGE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 604151367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7085817308 | ||||||||
| FaxNumber: | 7085817309 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2010 | ||||||||
| LastUpdateDate: | 06/25/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 164005258 | IL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 164005258 | 01 | IL | STATE OF ILLINOIS LICENSE | OTHER |