Provider Demographics
NPI:1982923017
Name:WAGNER, LEIGH ELIZABETH (RD, LD)
Entity type:Individual
Prefix:
First Name:LEIGH
Middle Name:ELIZABETH
Last Name:WAGNER
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11754 GARNETT ST
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66210-3449
Mailing Address - Country:US
Mailing Address - Phone:402-202-2494
Mailing Address - Fax:
Practice Address - Street 1:3901 RAINBOW BLVD
Practice Address - Street 2:MAILSTOP 1017
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66103-2937
Practice Address - Country:US
Practice Address - Phone:913-588-6208
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-05-28
Last Update Date:2010-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1586133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS1586OtherREGISTERED DIETITIAN