Provider Demographics
NPI:1346511078
Name:BULLOCK, LESLIE ANN (MOE, RD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:BULLOCK
Suffix:
Gender:F
Credentials:MOE, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:195 MCGREGOR ST STE 312
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03102-3749
Mailing Address - Country:US
Mailing Address - Phone:603-663-6297
Mailing Address - Fax:603-663-6735
Practice Address - Street 1:195 MCGREGOR ST STE 312
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102-3749
Practice Address - Country:US
Practice Address - Phone:603-663-6297
Practice Address - Fax:603-663-6735
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH173133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered