Provider Demographics
NPI:1568869345
Name:ARCHULETA, LESLIE JADE (MD)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:JADE
Last Name:ARCHULETA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:LESLIE
Other - Middle Name:JADE
Other - Last Name:BACHELOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:750 E ADAMS ST
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13210-2306
Mailing Address - Country:US
Mailing Address - Phone:315-464-4006
Mailing Address - Fax:
Practice Address - Street 1:750 E ADAMS ST
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13210-2306
Practice Address - Country:US
Practice Address - Phone:315-464-5162
Practice Address - Fax:315-464-4613
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-23
Last Update Date:2021-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NMLN-0959133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program