Healthcare Provider Details

I. General information

NPI: 1831029396
Provider Name (Legal Business Name): RENAE E HARRISON RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2026
Last Update Date: 05/19/2026
Certification Date: 05/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 E CHEROKEE ST
SPRINGFIELD MO
65804-2203
US

IV. Provider business mailing address

2752 S MEADOWBROOK AVE APT E103
SPRINGFIELD MO
65807-5928
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-3422
  • Fax:
Mailing address:
  • Phone: 417-820-3422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2026018608
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: