Provider Demographics
NPI:1891816864
Name:MAAG, LEOTA R (RN, CDE)
Entity type:Individual
Prefix:MRS
First Name:LEOTA
Middle Name:R
Last Name:MAAG
Suffix:
Gender:F
Credentials:RN, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1432 SOUTHWEST BLVD
Mailing Address - Street 2:PO BOX 1128
Mailing Address - City:JEFFERSON CITY
Mailing Address - State:MO
Mailing Address - Zip Code:65109-2444
Mailing Address - Country:US
Mailing Address - Phone:573-632-5092
Mailing Address - Fax:573-632-5857
Practice Address - Street 1:1432 SOUTHWEST BLVD
Practice Address - Street 2:
Practice Address - City:JEFFERSON CITY
Practice Address - State:MO
Practice Address - Zip Code:65109-2444
Practice Address - Country:US
Practice Address - Phone:573-632-5092
Practice Address - Fax:573-632-5857
Is Sole Proprietor?:No
Enumeration Date:2007-04-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO086461163WD0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WD0400XNursing Service ProvidersRegistered NurseDiabetes Educator