Healthcare Provider Details

I. General information

NPI: 1104489954
Provider Name (Legal Business Name): ALIXANDRA BIANCA LEESTMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2019
Last Update Date: 04/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2202 S CEDAR ST STE 300
TACOMA WA
98405-2318
US

IV. Provider business mailing address

PO BOX 5299 MS: 737-3-PCON
TACOMA WA
98415-0299
US

V. Phone/Fax

Practice location:
  • Phone: 253-301-5280
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License NumberDI60943877
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: