Healthcare Provider Details

I. General information

NPI: 1669817292
Provider Name (Legal Business Name): REBECCA NICOLE BOAN M.S., R.D., L.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2013
Last Update Date: 09/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4963 W 135TH ST
LEAWOOD KS
66224-6901
US

IV. Provider business mailing address

15583 BALLENTINE ST
OVERLAND PARK KS
66221-9785
US

V. Phone/Fax

Practice location:
  • Phone: 913-814-8222
  • Fax:
Mailing address:
  • Phone: 913-669-0708
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number1775
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: