Provider Demographics
NPI:1962688499
Name:CORNETT, LESLIE ROBERTS (MSH, RDN, LDN, CDCES)
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:ROBERTS
Last Name:CORNETT
Suffix:
Gender:F
Credentials:MSH, RDN, LDN, CDCES
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4015 BANNER CREST DR
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-8370
Mailing Address - Country:US
Mailing Address - Phone:423-475-0120
Mailing Address - Fax:
Practice Address - Street 1:4015 BANNER CREST DR
Practice Address - Street 2:
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-8370
Practice Address - Country:US
Practice Address - Phone:423-475-0120
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-15
Last Update Date:2025-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA892550133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered