Provider Demographics
NPI:1831268762
Name:CORDELLA-SIMON, LESLIE NOEL (MED,RD,LDN,CDE)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:NOEL
Last Name:CORDELLA-SIMON
Suffix:
Gender:F
Credentials:MED,RD,LDN,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:54 CENTRAL AVENUE,
Mailing Address - Street 2:APT 3
Mailing Address - City:MILTON
Mailing Address - State:MA
Mailing Address - Zip Code:02186-2916
Mailing Address - Country:US
Mailing Address - Phone:508-737-7084
Mailing Address - Fax:866-851-7082
Practice Address - Street 1:54 CENTRAL AVE
Practice Address - Street 2:APT 3
Practice Address - City:MILTON
Practice Address - State:MA
Practice Address - Zip Code:02186-2916
Practice Address - Country:US
Practice Address - Phone:508-737-7084
Practice Address - Fax:866-851-7082
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALDN800133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0093Medicare ID - Type Unspecified