1295193084 NPI number — LEILA DAVIS

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295193084 NPI number — LEILA DAVIS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEILA DAVIS
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1295193084
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/08/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
17806 80TH AVE NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENMORE
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98028-1806
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
870-224-5492
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
17806 80TH AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENMORE
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98028-1806
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
870-224-5492
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/08/2016

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
LEILA
Authorized Official Middle Name:
ALEXANDRA
Authorized Official Title or Position:
NUTRITION AND DIET TECHNICINA
Authorized Official Telephone Number:
870-224-5492

Provider Taxonomy Codes

  • Taxonomy code: 136A00000X , with the licence number:  1057724 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1057724 . This is a "COMMISSION ON DIETETIC REGISTRATION" identifier , issued by the state of ( WA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com