Provider Demographics
NPI:1942917448
Name:LESLIE, SUSAN LYNN (MS, RDN)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:LYNN
Last Name:LESLIE
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3051 PRIMROSE LANE
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-3213
Mailing Address - Country:US
Mailing Address - Phone:734-604-8266
Mailing Address - Fax:833-315-0019
Practice Address - Street 1:7810 BALLANTYNE COMMONS PKWY STE 221
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-3416
Practice Address - Country:US
Practice Address - Phone:704-995-3434
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-03
Last Update Date:2022-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Renal
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic