Provider Demographics
NPI:1376011213
Name:GIAMBALVO, LESLIE MICHELE (RD)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:MICHELE
Last Name:GIAMBALVO
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 1:5025 N OKETO AVE
Mailing Address - Street 2:
Mailing Address - City:HARWOOD HEIGHTS
Mailing Address - State:IL
Mailing Address - Zip Code:60706-3530
Mailing Address - Country:US
Mailing Address - Phone:773-206-5094
Mailing Address - Fax:
Practice Address - Street 1:3249 OAK PARK AVE
Practice Address - Street 2:
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3429
Practice Address - Country:US
Practice Address - Phone:708-783-3077
Practice Address - Fax:708-783-0654
Is Sole Proprietor?:No
Enumeration Date:2018-11-08
Last Update Date:2018-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164.003848133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered