MEDICARE: ANNIE MARIE NELSON 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	2001025280	MO

General Provider Information

NPI Number	:	1780867085
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNIE MARIE NELSON RD

Provider Business Mailing Address
First Line	:	10604 WALROND AVE
Second Line	:	PO BOX 46213
City	:	KANSAS CITY
State	:	MO
Zip	:	64137-1755
Country	:	US
Telephone Number	:	816-966-0924
Fax Number	:

Provider Business Practice Location Address
First Line	:	1610 SOUTHRIDGE DR
Second Line	:
City	:	JEFFERSON CITY
State	:	MO
Zip	:	65102-9743
Country	:	US
Telephone Number	:	573-751-6303
Fax Number	:

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

Provider Enumeration Date	:	12/10/2007
Last Update Date	:	12/10/2007

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