Healthcare Provider Details

I. General information

NPI: 1407897168
Provider Name (Legal Business Name): LEAH M WALTERS RDLD/CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LEAH M HELLER

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 08/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 PLEASANT AVE S
PARK RAPIDS MN
56470-1440
US

IV. Provider business mailing address

PO BOX 6001
FARGO ND
58108-6001
US

V. Phone/Fax

Practice location:
  • Phone: 218-732-2800
  • Fax: 218-732-2874
Mailing address:
  • Phone: 218-732-2800
  • Fax: 218-732-2874

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number1507
License Number StateMN
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1507
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: