MEDICARE: RENAE E HARRISON 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	2026018608	MO

General Provider Information

NPI Number	:	1831029396
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENAE E HARRISON RD

Provider Business Mailing Address
First Line	:	2752 S MEADOWBROOK AVE APT E103
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65807-5928
Country	:	US
Telephone Number	:	417-820-3422
Fax Number	:

Provider Business Practice Location Address
First Line	:	1235 E CHEROKEE ST
Second Line	:
City	:	SPRINGFIELD
State	:	MO
Zip	:	65804-2203
Country	:	US
Telephone Number	:	417-820-3422
Fax Number	:

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

Provider Enumeration Date	:	05/19/2026
Last Update Date	:	05/19/2026

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