Provider Demographics
NPI:1003474545
Name:WEBER, LEAH
Entity type:Individual
Prefix:MRS
First Name:LEAH
Middle Name:
Last Name:WEBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5992 BERRYHILL RD STE 203
Mailing Address - Street 2:
Mailing Address - City:MILTON
Mailing Address - State:FL
Mailing Address - Zip Code:32570-1014
Mailing Address - Country:US
Mailing Address - Phone:850-626-5121
Mailing Address - Fax:
Practice Address - Street 1:5992 BERRYHILL RD STE 203
Practice Address - Street 2:
Practice Address - City:MILTON
Practice Address - State:FL
Practice Address - Zip Code:32570-1014
Practice Address - Country:US
Practice Address - Phone:850-626-5121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND7985133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered