Provider Demographics
NPI:1073051900
Name:LADNER, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:LADNER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4733 W MOUNTAIN VIEW DR
Mailing Address - Street 2:UNIT 1
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92116-1654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4733 W MOUNTAIN VIEW DR
Practice Address - Street 2:UNIT 1
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92116-1654
Practice Address - Country:US
Practice Address - Phone:662-292-1865
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-12
Last Update Date:2017-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS86046587133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered