Healthcare Provider Details

I. General information

NPI: 1104317379
Provider Name (Legal Business Name): DENISE J MCENANEY
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2018
Last Update Date: 05/23/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PERSHING AVE
SHENANDOAH IA
51601-2355
US

IV. Provider business mailing address

101 N 12TH ST
TARKIO MO
64491-1411
US

V. Phone/Fax

Practice location:
  • Phone: 712-246-7400
  • Fax:
Mailing address:
  • Phone: 660-623-9128
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2018000658
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number091770
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: