Provider Demographics
NPI:1104233212
Name:LESLIE, MELISSA ANNE
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:ANNE
Last Name:LESLIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MELISSA
Other - Middle Name:ANNE
Other - Last Name:THOMPSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RD, LLD
Mailing Address - Street 1:3901 RAINBOW BLVD
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66160-7201
Mailing Address - Country:US
Mailing Address - Phone:913-945-8335
Mailing Address - Fax:913-588-4060
Practice Address - Street 1:3901 RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66160-7201
Practice Address - Country:US
Practice Address - Phone:913-945-8335
Practice Address - Fax:913-588-4060
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-21
Last Update Date:2014-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
879827133V00000X
MO2004023272133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered