Healthcare Provider Details

I. General information

NPI: 1982238069
Provider Name (Legal Business Name): LEANNE MICHELLE WITEK RD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10803 SE CHERRY BLOSSOM DR
PORTLAND OR
97216-3107
US

IV. Provider business mailing address

4130 SW 117TH AVE STE 473
BEAVERTON OR
97005-5606
US

V. Phone/Fax

Practice location:
  • Phone: 503-840-0671
  • Fax: 503-566-6067
Mailing address:
  • Phone: 503-847-9952
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberLD-D-10200107
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: