Healthcare Provider Details

I. General information

NPI: 1891900072
Provider Name (Legal Business Name): NELSON LEIGH KENNER RD, CDE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1432 SOUTHWEST BLVD
JEFFERSON CITY MO
65109-2444
US

IV. Provider business mailing address

9950 S ROUTE N
COLUMBIA MO
65203-8997
US

V. Phone/Fax

Practice location:
  • Phone: 573-632-5093
  • Fax:
Mailing address:
  • Phone: 573-657-1990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2001022274
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: