Provider Demographics
NPI:1598120768
Name:LEITZ, SANDRA KAYE (RD, CDE)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:KAYE
Last Name:LEITZ
Suffix:
Gender:F
Credentials:RD, CDE
Other - Prefix:MS
Other - First Name:SANDRA
Other - Middle Name:KAYE
Other - Last Name:LARSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2525 E ROOSEVELT ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-4948
Mailing Address - Country:US
Mailing Address - Phone:602-344-5104
Mailing Address - Fax:602-344-5578
Practice Address - Street 1:2525 E ROOSEVELT ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-4948
Practice Address - Country:US
Practice Address - Phone:602-344-5104
Practice Address - Fax:602-344-5578
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-15
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ714444133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered