Provider Demographics
NPI:1336580307
Name:DAVIS, LESLIE CONGER (RD, LD, CDE)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:CONGER
Last Name:DAVIS
Suffix:
Gender:F
Credentials:RD, LD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2709 LEGISLATIVE LN
Mailing Address - Street 2:
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-8037
Mailing Address - Country:US
Mailing Address - Phone:770-718-6736
Mailing Address - Fax:
Practice Address - Street 1:3617 BRASELTON HWY
Practice Address - Street 2:SUITE 104
Practice Address - City:DACULA
Practice Address - State:GA
Practice Address - Zip Code:30019-4667
Practice Address - Country:US
Practice Address - Phone:770-718-6736
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-08
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD001208133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered