Healthcare Provider Details

I. General information

NPI: 1518262146
Provider Name (Legal Business Name): LEIGHANNE COLLIER RD LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2011
Last Update Date: 03/24/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

910 RODNEY VISTA BLVD
CAPE GIRARDEAU MO
63701-4351
US

IV. Provider business mailing address

910 RODNEY VISTA BLVD
CAPE GIRARDEAU MO
63701-4351
US

V. Phone/Fax

Practice location:
  • Phone: 573-576-3255
  • Fax:
Mailing address:
  • Phone: 573-576-3255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number2008008963
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2008008963
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number2008008963
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code133VN1006X
TaxonomyMetabolic Nutrition Registered Dietitian
License Number2008008963
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: