MEDICARE: LEANNE RENEE DONOVAN MS, RD, LD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133V00000X	Registered Dietitian	2010012940	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1861674871	OTHER	MO	INSIGHT DIETITIANS

General Provider Information

NPI Number	:	1124308648
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEANNE RENEE DONOVAN MS, RD, LD

Provider Business Mailing Address
First Line	:	705 BROWNELL AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63122-3234
Country	:	US
Telephone Number	:	314-623-9946
Fax Number	:

Provider Business Practice Location Address
First Line	:	705 BROWNELL AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63122-3234
Country	:	US
Telephone Number	:	314-623-9946
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/29/2011
Last Update Date	:	10/09/2013

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