Provider Demographics
NPI:1912136805
Name:DIANE, LEISHA (LMT)
Entity Type:Individual
Prefix:
First Name:LEISHA
Middle Name:
Last Name:DIANE
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7019 ALONZO AVE NW
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98117-5323
Mailing Address - Country:US
Mailing Address - Phone:206-769-4363
Mailing Address - Fax:
Practice Address - Street 1:7019 ALONZO AVE NW
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98117-5323
Practice Address - Country:US
Practice Address - Phone:206-769-4363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-13
Last Update Date:2009-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00004859174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist