Provider Demographics
NPI:1225307325
Name:EDMUNDS, LESLIE CLEM (MPH, RD, LD)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:CLEM
Last Name:EDMUNDS
Suffix:
Gender:F
Credentials:MPH, RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4549 OLD MILL RD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45502-9747
Mailing Address - Country:US
Mailing Address - Phone:937-206-1131
Mailing Address - Fax:
Practice Address - Street 1:4359 E ENON RD
Practice Address - Street 2:
Practice Address - City:YELLOW SPRINGS
Practice Address - State:OH
Practice Address - Zip Code:45387-9708
Practice Address - Country:US
Practice Address - Phone:937-206-1131
Practice Address - Fax:937-917-8048
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-19
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1013816133V00000X
OH3262133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0166806Medicaid