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NPI Code Detail

MEDICARE: CARRIE DEA WAMBLE RD LD

MEDICARE: CARRIE DEA WAMBLE 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
1133V00000XRegistered Dietitian2024008981MO

General Provider Information

NPI Number : 1801644984
Entity Type Code : Individual
Provider Name (Legal Business Name) : CARRIE DEA WAMBLE RD LD
Provider Business Mailing Address
First Line : 106 HEATHER ST
Second Line :
City : BERTRAND
State : MO
Zip : 63823-9766
Country : US
Telephone Number : 573-233-4215
Fax Number :
Provider Business Practice Location Address
First Line : 3095 LEXINGTON AVE STE 200
Second Line :
City : CAPE GIRARDEAU
State : MO
Zip : 63701-2629
Country : US
Telephone Number : 573-987-5355
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 05/13/2024
Last Update Date : 05/13/2024

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Directions to “ CARRIE DEA WAMBLE RD LD” Practice Location

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