Provider Demographics
NPI:1104121680
Name:TANNER, LEAH M (RD)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:M
Last Name:TANNER
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 1:84 SANTA ROSA ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93405-1812
Mailing Address - Country:US
Mailing Address - Phone:805-548-8585
Mailing Address - Fax:805-548-8589
Practice Address - Street 1:84 SANTA ROSA ST
Practice Address - Street 2:SUITE A
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-1812
Practice Address - Country:US
Practice Address - Phone:805-548-8585
Practice Address - Fax:805-548-8589
Is Sole Proprietor?:No
Enumeration Date:2011-01-14
Last Update Date:2014-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA919327133VN1005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA919327OtherAMERICAN DIETETIC ASSOCIATION MEMBERSHIP
CA919327OtherAMERICAN DIETETIC ASSOCIATION MEMBERSHIP