Provider Demographics
NPI:1770811283
Name:PRIVETT, DAWN LARA (RD)
Entity type:Individual
Prefix:
First Name:DAWN
Middle Name:LARA
Last Name:PRIVETT
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 W 25TH TER S
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:MO
Mailing Address - Zip Code:64052-3210
Mailing Address - Country:US
Mailing Address - Phone:816-719-2743
Mailing Address - Fax:
Practice Address - Street 1:1214 W 25TH TER S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:MO
Practice Address - Zip Code:64052-3210
Practice Address - Country:US
Practice Address - Phone:816-719-2743
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-11-20
Last Update Date:2009-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20000171728133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered