Provider Demographics
NPI:1285905521
Name:WILEY, LESLEY ANNE (MS RD)
Entity type:Individual
Prefix:MRS
First Name:LESLEY
Middle Name:ANNE
Last Name:WILEY
Suffix:
Gender:F
Credentials:MS RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 E CAMPBELL AVE STE 6B
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-2126
Mailing Address - Country:US
Mailing Address - Phone:408-370-7731
Mailing Address - Fax:408-370-7732
Practice Address - Street 1:621 E CAMPBELL AVE STE 6B
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-2126
Practice Address - Country:US
Practice Address - Phone:408-370-7731
Practice Address - Fax:408-370-7732
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-18
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1053707133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered