Provider Demographics
NPI:1609182047
Name:LOVELY, LESLEY RAE (RD)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:RAE
Last Name:LOVELY
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 1:3100 SUFFOLK DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-4060
Mailing Address - Country:US
Mailing Address - Phone:817-453-9887
Mailing Address - Fax:
Practice Address - Street 1:3100 SUFFOLK DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-4060
Practice Address - Country:US
Practice Address - Phone:817-453-9887
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-23
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT04851133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered