Healthcare Provider Details

I. General information

NPI: 1871892083
Provider Name (Legal Business Name): ALYSE MEGAN FIELDS RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/28/2011
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1965 S FREMONT AVE STE 300
SPRINGFIELD MO
65804-2278
US

IV. Provider business mailing address

1965 S FREMONT AVE STE 300
SPRINGFIELD MO
65804-2278
US

V. Phone/Fax

Practice location:
  • Phone: 417-820-7731
  • Fax:
Mailing address:
  • Phone: 417-820-7731
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number2007022844
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: