MEDICARE: JENNA DENISE MOORE-LIESTER RD

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

General Provider Information

NPI Number	:	1538655097
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JENNA DENISE MOORE-LIESTER RD

Provider Business Mailing Address
First Line	:	6156 ROCKVILLE DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80923-3806
Country	:	US
Telephone Number	:	719-684-5754
Fax Number	:

Provider Business Practice Location Address
First Line	:	6156 ROCKVILLE DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80923-3806
Country	:	US
Telephone Number	:	719-684-5754
Fax Number	:

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

Provider Enumeration Date	:	07/09/2018
Last Update Date	:	01/24/2019

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