Provider Demographics
NPI:1295193084
Name:LEILA DAVIS
Entity Type:Organization
Organization Name:LEILA DAVIS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NUTRITION AND DIET TECHNICINA
Authorized Official - Prefix:
Authorized Official - First Name:LEILA
Authorized Official - Middle Name:ALEXANDRA
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:NDTR
Authorized Official - Phone:870-224-5492
Mailing Address - Street 1:17806 80TH AVE NE
Mailing Address - Street 2:
Mailing Address - City:KENMORE
Mailing Address - State:WA
Mailing Address - Zip Code:98028-1806
Mailing Address - Country:US
Mailing Address - Phone:870-224-5492
Mailing Address - Fax:
Practice Address - Street 1:17806 80TH AVE NE
Practice Address - Street 2:
Practice Address - City:KENMORE
Practice Address - State:WA
Practice Address - Zip Code:98028-1806
Practice Address - Country:US
Practice Address - Phone:870-224-5492
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-08
Last Update Date:2016-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1057724136A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes136A00000XDietary & Nutritional Service ProvidersDietetic Technician, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1057724OtherCOMMISSION ON DIETETIC REGISTRATION