Provider Demographics
NPI:1720243074
Name:GAILLARD, LESLIE (RD)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:GAILLARD
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 1:10300 ROCKY FORD CT
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-8907
Mailing Address - Country:US
Mailing Address - Phone:415-606-7407
Mailing Address - Fax:919-800-3641
Practice Address - Street 1:156 MINE LAKE CT
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27615-6417
Practice Address - Country:US
Practice Address - Phone:415-606-7407
Practice Address - Fax:919-800-3641
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-25
Last Update Date:2015-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL003806133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered