Provider Demographics
NPI:1982238069
Name:WITEK, LEANNE MICHELLE (RD)
Entity Type:Individual
Prefix:
First Name:LEANNE
Middle Name:MICHELLE
Last Name:WITEK
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4130 SW 117TH AVE STE 473
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-5606
Mailing Address - Country:US
Mailing Address - Phone:503-847-9952
Mailing Address - Fax:
Practice Address - Street 1:10803 SE CHERRY BLOSSOM DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-3107
Practice Address - Country:US
Practice Address - Phone:503-840-0671
Practice Address - Fax:503-566-6067
Is Sole Proprietor?:No
Enumeration Date:2020-02-27
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORLD-D-10200107133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered