Basic Information
| Provider Information | |||||||||
| NPI: | 1982687851 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAWES | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | ANNE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 WEST BUNNY AVENUE | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934582805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055976715 | ||||||||
| FaxNumber: | 8055976716 | ||||||||
| Practice Location | |||||||||
| Address1: | 1941 JOHNSON AVENUE | ||||||||
| Address2: | SUITE 301 | ||||||||
| City: | SAN LUIS OBISPO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934014175 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8055976715 | ||||||||
| FaxNumber: | 8055976716 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/23/2005 | ||||||||
| LastUpdateDate: | 12/26/2015 | ||||||||
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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 | 883324 | CA | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | GB179Z | 01 | CA | MEDICARE ID | OTHER |