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General NPI Number Information
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NPI Number | 1295193084
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Entity Type | Organization
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Legal Business Name | LEILA DAVIS
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Dates
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Enumeration Date | 02/08/2016
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Last Update Date | 02/08/2016
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Provider Practice Location Address
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Address Line | 17806 80TH AVE NE
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City | KENMORE
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State | WA
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Zip | 98028-1806
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Country | US
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Telephone | 870-224-5492
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Fax |
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Provider Business Mailing Address
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Address Line | 17806 80TH AVE NE
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City | KENMORE
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State | WA
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Zip | 98028-1806
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Country | US
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Telephone | 870-224-5492
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Fax |
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Authorized Official
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Title or Position | NUTRITION AND DIET TECHNICINA
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Name | LEILA ALEXANDRA DAVIS
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Credential | NDTR
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Telephone | 870-224-5492
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 136A00000X
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Taxonomy Name | Registered Dietetic Technician
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License Number | 1057724
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License Number State | AR
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