Basic Information
| Provider Information | |||||||||
| NPI: | 1851856041 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VANATTA | ||||||||
| FirstName: | LISA | ||||||||
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| Credential: | MS, RDN, CSP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 E CAMELBACK RD STE 250 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850182327 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029331813 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1919 E THOMAS RD BLDG 3 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850167710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6029330970 | ||||||||
| FaxNumber: | 6029334253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2019 | ||||||||
| LastUpdateDate: | 07/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133VN1004X | N | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric | 133VN1004X | 718221 | AZ | Y | Dietary & Nutritional Service Providers | Dietitian, Registered | Nutrition, Pediatric |
ID Information
| ID | Type | State | Issuer | Description | 327149 | 05 | AZ | MEDICAID |