=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780625517
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LARAINE DELL WALTERS RD LD LPN
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/10/2006
-----------------------------------------------------
Last Update Date | 09/02/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 26799 OWENS DR
-----------------------------------------------------
City | LEBANON
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65536-9380
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-532-9411
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 9521 N AMBASSADOR DR. APT 3104
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64154
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-718-1218
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 2005030875
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------