Provider Demographics
NPI:1659613438
Name:LESKA, KELLY NICOLE (RD)
Entity Type:Individual
Prefix:MS
First Name:KELLY
Middle Name:NICOLE
Last Name:LESKA
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 1:820 S DAMEN AVE
Mailing Address - Street 2:DEPARTMENT 120
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60612-3728
Mailing Address - Country:US
Mailing Address - Phone:312-569-6427
Mailing Address - Fax:
Practice Address - Street 1:820 S DAMEN AVE
Practice Address - Street 2:DEPARTMENT 120
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60612-3728
Practice Address - Country:US
Practice Address - Phone:312-569-6427
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1069975133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered