Provider Demographics
NPI:1568839868
Name:HEALTHY GREEN NUTRITION, LLC
Entity Type:Organization
Organization Name:HEALTHY GREEN NUTRITION, LLC
Other - Org Name:HEALTHY GREEN NUTRITION, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VALARIE
Authorized Official - Middle Name:DIANE
Authorized Official - Last Name:GREENLEAF-KISNER
Authorized Official - Suffix:
Authorized Official - Credentials:MS, RDN, LD, CDCES
Authorized Official - Phone:316-253-2604
Mailing Address - Street 1:12210 E BOXTHORN ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-8263
Mailing Address - Country:US
Mailing Address - Phone:316-253-2604
Mailing Address - Fax:
Practice Address - Street 1:9415 E HARRY ST STE 407
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67207-5083
Practice Address - Country:US
Practice Address - Phone:316-253-2604
Practice Address - Fax:316-634-3789
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-22
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS20220205133NN1002X
KS717684133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, EducationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100210590AMedicaid
KS100210590AMedicaid