Provider Demographics
NPI:1083856322
Name:STEWART, LESLIE (RDLD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:STEWART
Suffix:
Gender:F
Credentials:RDLD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4281 CLUB DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30319-1148
Mailing Address - Country:US
Mailing Address - Phone:404-240-0560
Mailing Address - Fax:404-240-0560
Practice Address - Street 1:4281 CLUB DR NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30319-1148
Practice Address - Country:US
Practice Address - Phone:404-240-0560
Practice Address - Fax:404-240-0560
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-01
Last Update Date:2009-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA709124133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA709124OtherAMERICAN DIETETIC ASSOCIATION REGISTRATION NUMBER