Basic Information
| Provider Information | |||||||||
| NPI: | 1538257944 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KADRMAS | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | LRD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 737 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581220001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012342245 | ||||||||
| FaxNumber: | 7012343838 | ||||||||
| Practice Location | |||||||||
| Address1: | 737 BROADWAY | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581220001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7012342245 | ||||||||
| FaxNumber: | 7012343838 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/11/2006 | ||||||||
| LastUpdateDate: | 05/05/2014 | ||||||||
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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 | 133V00000X | 696 | ND | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 51340 | 05 | ND | MEDICAID |