Provider Demographics
NPI:1801319660
Name:OUELLETTE, LESLIE (RDN, LD)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:OUELLETTE
Suffix:
Gender:F
Credentials:RDN, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:402 WEBBER HILL RD
Mailing Address - Street 2:
Mailing Address - City:KENNEBUNK
Mailing Address - State:ME
Mailing Address - Zip Code:04043-6335
Mailing Address - Country:US
Mailing Address - Phone:207-837-4473
Mailing Address - Fax:
Practice Address - Street 1:40 MAIN ST
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005-5178
Practice Address - Country:US
Practice Address - Phone:207-837-4473
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-24
Last Update Date:2017-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEDI1103133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered