MEDICARE: VICTORIA LAUREN WASSNER RD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian

General Provider Information

NPI Number	:	1285263632
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VICTORIA LAUREN WASSNER RD

Provider Business Mailing Address
First Line	:	16000 GRANADA ST APT 210
Second Line	:
City	:	OVERLAND PARK
State	:	KS
Zip	:	66085-8459
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	16000 GRANADA ST APT 210
Second Line	:
City	:	OVERLAND PARK
State	:	KS
Zip	:	66085-8459
Country	:	US
Telephone Number	:	913-217-0991
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/07/2020
Last Update Date	:	02/01/2022

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