Provider Demographics
NPI:1407897168
Name:WALTERS, LEAH M (RDLD/CDE)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:M
Last Name:WALTERS
Suffix:
Gender:F
Credentials:RDLD/CDE
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:M
Other - Last Name:HELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 6001
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58108-6001
Mailing Address - Country:US
Mailing Address - Phone:218-732-2800
Mailing Address - Fax:218-732-2874
Practice Address - Street 1:705 PLEASANT AVE S
Practice Address - Street 2:
Practice Address - City:PARK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56470-1440
Practice Address - Country:US
Practice Address - Phone:218-732-2800
Practice Address - Fax:218-732-2874
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2012-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1507133NN1002X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN6300061OtherMEDICA #
MN1407897168Medicaid
MN6D677WAOtherMNBS #
MN6D679WAOtherMNBS #
MN6300062OtherMEDICA #
MN6300063OtherMEDICA #
MN15790OtherNDBS #
MN6D678WAOtherMNBS #
MN6D677WAOtherMNBS #
MN6300062OtherMEDICA #
MN710000104Medicare ID - Type UnspecifiedMN MEDICARE #
MN1407897168Medicaid
MN6300063OtherMEDICA #