Provider Demographics
NPI:1043754112
Name:JOY, LEAH (RD, IBCLC)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:
Last Name:JOY
Suffix:
Gender:F
Credentials:RD, IBCLC
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:
Other - Last Name:AGNEW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1310 E BIRCH AVE
Mailing Address - Street 2:
Mailing Address - City:COEUR D ALENE
Mailing Address - State:ID
Mailing Address - Zip Code:83814-4436
Mailing Address - Country:US
Mailing Address - Phone:315-244-0677
Mailing Address - Fax:
Practice Address - Street 1:1310 E BIRCH AVE
Practice Address - Street 2:
Practice Address - City:COEUR D ALENE
Practice Address - State:ID
Practice Address - Zip Code:83814-4436
Practice Address - Country:US
Practice Address - Phone:315-244-0677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-08
Last Update Date:2016-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-955133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered