Provider Demographics
NPI:1780625517
Name:WALTERS, LARAINE DELL (RD LD LPN)
Entity type:Individual
Prefix:MS
First Name:LARAINE
Middle Name:DELL
Last Name:WALTERS
Suffix:
Gender:F
Credentials:RD LD LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9521 N AMBASSADOR DR. APT 3104
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64154
Mailing Address - Country:US
Mailing Address - Phone:417-718-1218
Mailing Address - Fax:
Practice Address - Street 1:26799 OWENS DR
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-9380
Practice Address - Country:US
Practice Address - Phone:417-532-9411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2021-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005030875133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered