Healthcare Provider Details

I. General information

NPI: 1801177910
Provider Name (Legal Business Name): LEIGH ANN KOWALSKY-GOODWIN R.D.; CDE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2011
Last Update Date: 04/11/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45-180 MAHALANI PL #7
KANEOHE HI
96744
US

IV. Provider business mailing address

45-180 MAHALANI PL #7
KANEOHE HI
96744
US

V. Phone/Fax

Practice location:
  • Phone: 214-557-6675
  • Fax:
Mailing address:
  • Phone: 214-557-6675
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number889823
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: