Basic Information
Provider Information | |||||||||
NPI: | 1851545230 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | THORNE | ||||||||
FirstName: | LEILA | ||||||||
MiddleName: | DAWN | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | STALNAKER | ||||||||
OtherFirstName: | LEILA | ||||||||
OtherMiddleName: | DAWN | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 2077 | ||||||||
Address2: |   | ||||||||
City: | PORTLAND | ||||||||
State: | OR | ||||||||
PostalCode: | 972082077 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5034133900 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2121 NE 139TH ST STE 200 | ||||||||
Address2: |   | ||||||||
City: | VANCOUVER | ||||||||
State: | WA | ||||||||
PostalCode: | 986862316 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3604871777 | ||||||||
FaxNumber: | 3604871779 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/11/2008 | ||||||||
LastUpdateDate: | 04/09/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133NN1002X |   |   | N |   | Dietary & Nutritional Service Providers | Nutritionist | Nutrition, Education | 133V00000X |   |   | Y |   | Dietary & Nutritional Service Providers | Dietitian, Registered |   |
No ID Information.