Active NPI
Lisa Ann Licavoli, R.D.
- Registered Dietitian
- Newport Beach, CA
National Provider Identifier
1063915080
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Registered Dietitian
- License
- R-553289
- Practice address
- 2289 Redlands Dr
Newport Beach, CA 92660 - Phone
- (949) 646-4842
- Fax
- (949) 646-4978
- NPI assigned
- Mar 15, 2018
- Sex
- Female
- Sole proprietor
- Yes
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 2
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Nutritionist | 133N00000X | CA | ||
| Registered Dietitian | 133V00000X | R-553289 | CA | Primary |
Addresses
Primary practice location
2289 Redlands Dr
Newport Beach, CA 92660
Mailing address
2289 Redlands Dr
Newport Beach, CA 92660
Phone (949) 646-4842
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| R-553289 | CA | MD | Registered Dietitian |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1521072000000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1521072000000",
"number": "1063915080",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "2289 REDLANDS DR",
"city": "NEWPORT BEACH",
"state": "CA",
"postal_code": "92660",
"telephone_number": "949-646-4842",
"fax_number": "949-646-4978"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "2289 REDLANDS DR",
"city": "NEWPORT BEACH",
"state": "CA",
"postal_code": "92660",
"telephone_number": "949-646-4842",
"fax_number": "949-646-4978"
}
],
"practiceLocations": [],
"basic": {
"last_name": "LICAVOLI",
"first_name": "LISA",
"middle_name": "ANN",
"name_prefix": "Ms.",
"credential": "R.D.",
"sole_proprietor": "YES",
"sex": "F",
"enumeration_date": "2018-03-15",
"last_updated": "2018-03-15",
"status": "A"
},
"taxonomies": [
{
"code": "133N00000X",
"taxonomy_group": "",
"desc": "Nutritionist",
"state": "CA",
"license": null,
"primary": false
},
{
"code": "133V00000X",
"taxonomy_group": "",
"desc": "Dietitian, Registered",
"state": "CA",
"license": "R-553289",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Newport Beach, CA
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Mar 15, 2018; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.