Provider Demographics
NPI:1568437796
Name:REAGAN, JOANNA J (MS, MHA, RD, LD, CDE)
Entity Type:Individual
Prefix:
First Name:JOANNA
Middle Name:J
Last Name:REAGAN
Suffix:
Gender:F
Credentials:MS, MHA, RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21426 LANCASTER LN
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-3120
Mailing Address - Country:US
Mailing Address - Phone:573-774-6479
Mailing Address - Fax:
Practice Address - Street 1:126 MISSOURI AVE
Practice Address - Street 2:GENERAL LEONARD WOOD ARMY COMMUNITY HOSPITAL
Practice Address - City:FORT LEONARD WOOD
Practice Address - State:MO
Practice Address - Zip Code:65473-8952
Practice Address - Country:US
Practice Address - Phone:573-596-0531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2010-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT03948133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered