Healthcare Provider Details

I. General information

NPI: 1295193084
Provider Name (Legal Business Name): LEILA DAVIS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2016
Last Update Date: 02/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17806 80TH AVE NE
KENMORE WA
98028-1806
US

IV. Provider business mailing address

17806 80TH AVE NE
KENMORE WA
98028-1806
US

V. Phone/Fax

Practice location:
  • Phone: 870-224-5492
  • Fax:
Mailing address:
  • Phone: 870-224-5492
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code136A00000X
TaxonomyRegistered Dietetic Technician
License Number1057724
License Number StateAR

VIII. Authorized Official

Name: LEILA ALEXANDRA DAVIS
Title or Position: NUTRITION AND DIET TECHNICINA
Credential: NDTR
Phone: 870-224-5492