Healthcare Provider Details

I. General information

NPI: 1285247304
Provider Name (Legal Business Name): ABIGAIL L EADS RDN, LDN, CN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2020
Last Update Date: 08/28/2020
Certification Date: 08/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

153 DOWELL RD
RUSSELL SPRINGS KY
42642-4579
US

IV. Provider business mailing address

PO BOX 1610
RUSSELL SPRINGS KY
42642-1610
US

V. Phone/Fax

Practice location:
  • Phone: 270-866-4141
  • Fax:
Mailing address:
  • Phone: 270-866-4141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number245666
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: