Provider Demographics
NPI:1174763833
Name:LEATHAM, MILDRED K (MPH, RD, CHES)
Entity type:Individual
Prefix:MS
First Name:MILDRED
Middle Name:K
Last Name:LEATHAM
Suffix:
Gender:F
Credentials:MPH, RD, CHES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3250 WILSHIRE BOULVARD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90010
Mailing Address - Country:US
Mailing Address - Phone:323-361-3815
Mailing Address - Fax:
Practice Address - Street 1:4650 SUNSET BLVD. MS#115
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027
Practice Address - Country:US
Practice Address - Phone:323-361-3815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-02-20
Last Update Date:2009-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC964557133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered