Provider Demographics
NPI:1114242781
Name:ANDERSON, LESLIE MARIE (LDN RD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:MARIE
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:LDN RD
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:A
Other - Last Name:WIMBERLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1005 MAR WALT DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT WALTON BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32547-6707
Mailing Address - Country:US
Mailing Address - Phone:850-863-6600
Mailing Address - Fax:850-862-0972
Practice Address - Street 1:1005 MAR WALT DR
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-6707
Practice Address - Country:US
Practice Address - Phone:850-863-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-07
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLND9301133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered