Provider Demographics
NPI:1407121312
Name:KRUSE, LANA MARIE (RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:LANA
Middle Name:MARIE
Last Name:KRUSE
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18 AUVERGNE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63367-2030
Mailing Address - Country:US
Mailing Address - Phone:636-561-3179
Mailing Address - Fax:636-561-3179
Practice Address - Street 1:100 MEDICAL PLZ
Practice Address - Street 2:SUITE 1203
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-1366
Practice Address - Country:US
Practice Address - Phone:636-625-5424
Practice Address - Fax:636-625-5431
Is Sole Proprietor?:No
Enumeration Date:2012-03-12
Last Update Date:2012-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000175751133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic