Provider Demographics
NPI:1578687695
Name:LEISTMAN, PATRICIA CAROL (MS, RD, CDN)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:CAROL
Last Name:LEISTMAN
Suffix:
Gender:F
Credentials:MS, RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222 STATION PLAZA NORTH
Mailing Address - Street 2:SUITE 611
Mailing Address - City:MINEOLA
Mailing Address - State:NY
Mailing Address - Zip Code:11501
Mailing Address - Country:US
Mailing Address - Phone:516-663-2532
Mailing Address - Fax:516-663-2233
Practice Address - Street 1:120 MINEOLA BOULEVARD
Practice Address - Street 2:SUITE 210
Practice Address - City:MINEOLA
Practice Address - State:NY
Practice Address - Zip Code:11501
Practice Address - Country:US
Practice Address - Phone:516-663-4600
Practice Address - Fax:516-663-3070
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001517133N00000X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered133N00000XDietary & Nutritional Service ProvidersNutritionist
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, Registered