MEDICARE: ILSE LEIJONANCKER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist		CA

General Provider Information

NPI Number	:	1356044549
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ILSE LEIJONANCKER

Provider Business Mailing Address
First Line	:	21 NIETO AVE APT D
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90803-3347
Country	:	US
Telephone Number	:	562-240-3073
Fax Number	:

Provider Business Practice Location Address
First Line	:	21 NIETO AVE APT D
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90803-3347
Country	:	US
Telephone Number	:	562-240-3073
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2023
Last Update Date	:	03/24/2023

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Directions to “ ILSE LEIJONANCKER ” Practice Location

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