Provider Demographics
NPI:1669817292
Name:BOAN, REBECCA NICOLE (MS, RD, LD)
Entity Type:Individual
Prefix:MISS
First Name:REBECCA
Middle Name:NICOLE
Last Name:BOAN
Suffix:
Gender:F
Credentials:MS, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15583 BALLENTINE ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66221-9785
Mailing Address - Country:US
Mailing Address - Phone:913-669-0708
Mailing Address - Fax:
Practice Address - Street 1:4963 W 135TH ST
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66224-6901
Practice Address - Country:US
Practice Address - Phone:913-814-8222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-09
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1775133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic