Provider Demographics
NPI:1558605923
Name:MCCULLEY, LEAH PAIZ (RD)
Entity type:Individual
Prefix:
First Name:LEAH
Middle Name:PAIZ
Last Name:MCCULLEY
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 1:4904 S POWER RD
Mailing Address - Street 2:SUITE # 103-188
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85212-3609
Mailing Address - Country:US
Mailing Address - Phone:602-770-7611
Mailing Address - Fax:480-505-3077
Practice Address - Street 1:3420 S MERCY RD
Practice Address - Street 2:SUITE 312
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-0419
Practice Address - Country:US
Practice Address - Phone:602-770-7611
Practice Address - Fax:480-505-3077
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-24
Last Update Date:2012-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ954642133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered