Healthcare Provider Details

I. General information

NPI: 1417734088
Provider Name (Legal Business Name): CANDACE BROOKE LEA MS, RDN, LDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2023
Last Update Date: 09/08/2023
Certification Date: 09/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 ROGERS AVE
FORT SMITH AR
72903-4100
US

IV. Provider business mailing address

3556 W EARNHARDT DR
FAYETTEVILLE AR
72704-6091
US

V. Phone/Fax

Practice location:
  • Phone: 479-314-6000
  • Fax:
Mailing address:
  • Phone: 479-629-1878
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number967
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: