Provider Demographics
NPI:1477061372
Name:DICKERSON, LEAH ELSPETH (MS, RD, LDN)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:ELSPETH
Last Name:DICKERSON
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 REVOLUTION MILL DR APT 217
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-5675
Mailing Address - Country:US
Mailing Address - Phone:817-614-5105
Mailing Address - Fax:
Practice Address - Street 1:5100 MACKAY RD
Practice Address - Street 2:
Practice Address - City:JAMESTOWN
Practice Address - State:NC
Practice Address - Zip Code:27282-9761
Practice Address - Country:US
Practice Address - Phone:336-855-5596
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-14
Last Update Date:2018-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL005178133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education