Provider Demographics
NPI:1104992189
Name:LESLIE, REBECCA A (RD)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:LESLIE
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 1:15606 258TH PL SE
Mailing Address - Street 2:
Mailing Address - City:ISSAQUAH
Mailing Address - State:WA
Mailing Address - Zip Code:98027-8257
Mailing Address - Country:US
Mailing Address - Phone:206-205-1940
Mailing Address - Fax:206-205-5499
Practice Address - Street 1:1404 CENTRAL AVE S
Practice Address - Street 2:SUITE 112
Practice Address - City:KENT
Practice Address - State:WA
Practice Address - Zip Code:98032-7433
Practice Address - Country:US
Practice Address - Phone:206-205-1940
Practice Address - Fax:206-205-5499
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI00000657133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8270118Medicaid