Healthcare Provider Details

I. General information

NPI: 1720091028
Provider Name (Legal Business Name): RAEGAN HEANSSLER M.S., R.D., L.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VA MEDICAL CENTER 1 VA CENTER
AUGUSTA ME
04330
US

IV. Provider business mailing address

60 MARBLE POINT RD
MOUNT VERNON ME
04352
US

V. Phone/Fax

Practice location:
  • Phone: 207-623-8411
  • Fax:
Mailing address:
  • Phone: 207-495-3356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number846555
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: