Provider Demographics
NPI:1205294246
Name:LEASK, SHAWN
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:
Last Name:LEASK
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 1:18 CAMPUS BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-3240
Mailing Address - Country:US
Mailing Address - Phone:215-932-6789
Mailing Address - Fax:
Practice Address - Street 1:18 CAMPUS BLVD STE 100
Practice Address - Street 2:
Practice Address - City:NEWTOWN SQUARE
Practice Address - State:PA
Practice Address - Zip Code:19073-3240
Practice Address - Country:US
Practice Address - Phone:215-932-6789
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-05
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADN004915133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered