Healthcare Provider Details

I. General information

NPI: 1780625517
Provider Name (Legal Business Name): LARAINE DELL WALTERS RD LD LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26799 OWENS DR
LEBANON MO
65536-9380
US

IV. Provider business mailing address

9521 N AMBASSADOR DR. APT 3104
KANSAS CITY MO
64154
US

V. Phone/Fax

Practice location:
  • Phone: 417-532-9411
  • Fax:
Mailing address:
  • Phone: 417-718-1218
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2005030875
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: