Provider Demographics
NPI:1235780990
Name:LEASK, KATIE JO (RD, LD, IBCLC)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:JO
Last Name:LEASK
Suffix:
Gender:F
Credentials:RD, LD, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:352 KIMBERLY DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-3821
Mailing Address - Country:US
Mailing Address - Phone:208-521-4079
Mailing Address - Fax:
Practice Address - Street 1:2375 CORONADO ST
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7407
Practice Address - Country:US
Practice Address - Phone:208-522-4600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-24
Last Update Date:2019-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDL-62086174N00000X
IDD-655133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No174N00000XOther Service ProvidersLactation Consultant, Non-RN