Provider Demographics
NPI:1386726057
Name:GREENLEAF-KISNER, VALARIE DIANE (MS, RD, LD,CDCES)
Entity type:Individual
Prefix:
First Name:VALARIE
Middle Name:DIANE
Last Name:GREENLEAF-KISNER
Suffix:
Gender:F
Credentials:MS, RD, LD,CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
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
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS00047133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100210590FMedicaid
KS130432OtherBLUECROSS BLUE SHIELD
KS100210590FMedicaid