Basic Information
| Provider Information | |||||||||
| NPI: | 1710086277 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETTER | ||||||||
| FirstName: | LYSSA | ||||||||
| MiddleName: | MERRIAM | ||||||||
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| Credential: | MS,RD,LDN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 13 PINECREST RD | ||||||||
| Address2: | |||||||||
| City: | ANDOVER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018105712 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786870156 | ||||||||
| FaxNumber: | 9786819075 | ||||||||
| Practice Location | |||||||||
| Address1: | CARITAS HOLY FAMILY HOSPITAL 70 EAST STREET | ||||||||
| Address2: | CONVENT BUILDING | ||||||||
| City: | METHUEN | ||||||||
| State: | MA | ||||||||
| PostalCode: | 01844 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786870156 | ||||||||
| FaxNumber: | 9786819075 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 826 | MA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 701743 | 01 | MA | CDR ID # | OTHER | 826 | 01 | MA | DIETITIAN LICENSE # | OTHER |