Provider Demographics
NPI:1275879041
Name:ANDERSON, LESLIE V (RD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:V
Last Name:ANDERSON
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 W 1600 S
Mailing Address - Street 2:
Mailing Address - City:WOODS CROSS
Mailing Address - State:UT
Mailing Address - Zip Code:84087-1606
Mailing Address - Country:US
Mailing Address - Phone:801-927-7970
Mailing Address - Fax:
Practice Address - Street 1:609 W 1600 S
Practice Address - Street 2:
Practice Address - City:WOODS CROSS
Practice Address - State:UT
Practice Address - Zip Code:84087-1606
Practice Address - Country:US
Practice Address - Phone:801-927-7970
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-21
Last Update Date:2012-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT6878902-4901133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered