Healthcare Provider Details

I. General information

NPI: 1952957045
Provider Name (Legal Business Name): LIBBY ANN DOMINIK R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/14/2019
Last Update Date: 08/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4386 CAPPELN OSAGE RD
AUGUSTA MO
63332-1118
US

IV. Provider business mailing address

4386 CAPPELN OSAGE RD
AUGUSTA MO
63332-1118
US

V. Phone/Fax

Practice location:
  • Phone: 636-459-7273
  • Fax:
Mailing address:
  • Phone: 636-459-7273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number850733
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: