Healthcare Provider Details

I. General information

NPI: 1447054747
Provider Name (Legal Business Name): LEAH RACHEL WUNDROW RDN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2025
Last Update Date: 04/03/2025
Certification Date: 04/03/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5135 HIGHLANDS LAKEVIEW LOOP
LAKELAND FL
33812-5039
US

IV. Provider business mailing address

5135 HIGHLANDS LAKEVIEW LOOP
LAKELAND FL
33812-5039
US

V. Phone/Fax

Practice location:
  • Phone: 317-473-5152
  • Fax:
Mailing address:
  • Phone: 317-473-5152
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberND8964
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: