=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497430979
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LEAH ROSE KOSTOS MBA, RDN, LDN, CPT
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/21/2023
-----------------------------------------------------
Last Update Date | 03/22/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1433 N WATER ST STE 400
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53202-2603
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-672-1381
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1108 N MILWAUKEE ST UNIT 119
-----------------------------------------------------
City | MILWAUKEE
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53202-3152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 262-672-1381
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 164009226
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 133V00000X
-----------------------------------------------------
Taxonomy Name | Registered Dietitian
-----------------------------------------------------
License Number | 564929
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------