Individual
KATIE JO LEASK
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
RD, LD, IBCLC
Contact information
Practice address
2375 CORONADO ST, IDAHO FALLS, ID 83404-7407
(208) 522-4600
Mailing address
352 KIMBERLY DR, IDAHO FALLS, ID 83401-3821
(208) 521-4079
Taxonomy
Speciality
Code
Description
License number
State
133V00000X
Registered Dietitian
Primary
D-655
ID
174N00000X
Lactation Consultant (Non-RN)
L-62086
ID
Other
Enumeration date
09/24/2019
Last updated
09/24/2019
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