Basic Information
| Provider Information | |||||||||
| NPI: | 1932353406 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LISOWSKI | ||||||||
| FirstName: | MONIQUE | ||||||||
| MiddleName: | L | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | R.D., L.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | DANTZLER | ||||||||
| OtherFirstName: | MONIQUE | ||||||||
| OtherMiddleName: | L | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | R.D., L.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 13000 BRUCE B DOWNS BLVD | ||||||||
| Address2: | ATTN: LAKELAND CBOC CLINIC | ||||||||
| City: | TAMPA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 336124745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8139722000 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4231 SOUTH PIPKIN ROAD | ||||||||
| Address2: | |||||||||
| City: | LAKELAND | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8633234194 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2008 | ||||||||
| LastUpdateDate: | 12/05/2019 | ||||||||
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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 | 133VN1201X | ND4795 | FL | N | 133V00000X | ND 4795 | FL | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.