Provider Demographics
NPI:1720371354
Name:DAVIS LESH, KRISTIN JO (RD)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:JO
Last Name:DAVIS LESH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:KRISTIN
Other - Middle Name:JO
Other - Last Name:DAVIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:1115 SE 164TH AVE
Mailing Address - Street 2:DEPT. 358
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-9324
Mailing Address - Country:US
Mailing Address - Phone:360-729-1462
Mailing Address - Fax:360-729-3104
Practice Address - Street 1:1615 DELAWARE ST
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2367
Practice Address - Country:US
Practice Address - Phone:360-501-3601
Practice Address - Fax:360-501-3648
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-16
Last Update Date:2016-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1042133V00000X
WADI60209738133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAG8936871Medicare UPIN