Provider Demographics
NPI:1790853745
Name:LEIDNER, KIM MARIE (MSRD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:KIM
Middle Name:MARIE
Last Name:LEIDNER
Suffix:
Gender:F
Credentials:MSRD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 STRATFORD AVE
Mailing Address - Street 2:
Mailing Address - City:GREENLAWN
Mailing Address - State:NY
Mailing Address - Zip Code:11740-2519
Mailing Address - Country:US
Mailing Address - Phone:631-368-3706
Mailing Address - Fax:631-368-1027
Practice Address - Street 1:986 SUNRISE HWY
Practice Address - Street 2:
Practice Address - City:WEST BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11704-6111
Practice Address - Country:US
Practice Address - Phone:631-587-6060
Practice Address - Fax:631-587-1364
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL806597133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5457751OtherCIGNA
NYAZ00894OtherMDNY
NY3C7122OtherHEALTHNET
NY8099804OtherGHI
NY2595970OtherAETNA
NYIG0951OtherBLUE CROSS
NYP2720854OtherOXFORD