Healthcare Provider Details

I. General information

NPI: 1720054505
Provider Name (Legal Business Name): LESLYE ANN WIPF R.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2006
Last Update Date: 02/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

911 E 20TH ST
SIOUX FALLS SD
57105-1048
US

IV. Provider business mailing address

PO BOX 86370
SIOUX FALLS SD
57118-6370
US

V. Phone/Fax

Practice location:
  • Phone: 605-322-7600
  • Fax: 605-322-7601
Mailing address:
  • Phone: 605-322-7510
  • Fax: 605-322-6475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number0270
License Number StateSD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: