Provider Demographics
NPI:1912141037
Name:DALLDORF, LEA ANN (MT-BC)
Entity Type:Individual
Prefix:MS
First Name:LEA
Middle Name:ANN
Last Name:DALLDORF
Suffix:
Gender:F
Credentials:MT-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:804 COWELL ST APT B
Mailing Address - Street 2:
Mailing Address - City:PAOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66071-2000
Mailing Address - Country:US
Mailing Address - Phone:913-731-5961
Mailing Address - Fax:
Practice Address - Street 1:804 COWELL ST APT B
Practice Address - Street 2:
Practice Address - City:PAOLA
Practice Address - State:KS
Practice Address - Zip Code:66071-2000
Practice Address - Country:US
Practice Address - Phone:913-731-5961
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor