Provider Demographics
NPI:1932572682
Name:EDISON, LEONDA
Entity Type:Individual
Prefix:
First Name:LEONDA
Middle Name:
Last Name:EDISON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13884 COLLINGHAM DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48205-1213
Mailing Address - Country:US
Mailing Address - Phone:586-202-3172
Mailing Address - Fax:
Practice Address - Street 1:13884 COLLINGHAM DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-1213
Practice Address - Country:US
Practice Address - Phone:586-202-3172
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-03
Last Update Date:2015-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education