Basic Information
| Provider Information | |||||||||
| NPI: | 1407897168 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WALTERS | ||||||||
| FirstName: | LEAH | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RDLD/CDE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HELLER | ||||||||
| OtherFirstName: | LEAH | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 6001 | ||||||||
| Address2: | |||||||||
| City: | FARGO | ||||||||
| State: | ND | ||||||||
| PostalCode: | 581086001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187322800 | ||||||||
| FaxNumber: | 2187322874 | ||||||||
| Practice Location | |||||||||
| Address1: | 705 PLEASANT AVE S | ||||||||
| Address2: | |||||||||
| City: | PARK RAPIDS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 564701440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2187322800 | ||||||||
| FaxNumber: | 2187322874 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 08/08/2012 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133NN1002X | 1507 | MN | N | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education | 133V00000X | 1507 | MN | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
ID Information
| ID | Type | State | Issuer | Description | 6300061 | 01 | MN | MEDICA # | OTHER | 1407897168 | 05 | MN | MEDICAID | 6D677WA | 01 | MN | MNBS # | OTHER | 6D679WA | 01 | MN | MNBS # | OTHER | 6300062 | 01 | MN | MEDICA # | OTHER | 6300063 | 01 | MN | MEDICA # | OTHER | 15790 | 01 | MN | NDBS # | OTHER | 6D678WA | 01 | MN | MNBS # | OTHER |