Healthcare Provider Details

I. General information

NPI: 1518615483
Provider Name (Legal Business Name): LEEANNA MICHELLE MOY RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2022
Last Update Date: 03/10/2022
Certification Date: 03/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

927 CHURCHILL ST W
STILLWATER MN
55082-6605
US

IV. Provider business mailing address

7904 HALLMARK WAY
APPLE VALLEY MN
55124-7076
US

V. Phone/Fax

Practice location:
  • Phone: 651-430-4602
  • Fax:
Mailing address:
  • Phone: 952-288-3104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number86210207
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: