Provider Demographics
NPI:1962067199
Name:LEEDY, LAUREN ELIZABETH (RD)
Entity type:Individual
Prefix:MRS
First Name:LAUREN
Middle Name:ELIZABETH
Last Name:LEEDY
Suffix:
Gender:F
Credentials:RD
Other - Prefix:MS
Other - First Name:LAUREN
Other - Middle Name:ELIZABETH
Other - Last Name:GIBSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD
Mailing Address - Street 1:10530 ASHWORTH AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-8938
Mailing Address - Country:US
Mailing Address - Phone:509-318-4471
Mailing Address - Fax:
Practice Address - Street 1:10530 ASHWORTH AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-8938
Practice Address - Country:US
Practice Address - Phone:509-318-4471
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-02
Last Update Date:2019-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WADI60650272133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered