Provider Demographics
NPI:1154024321
Name:BLANCH, LESLEE ELYSE (RD)
Entity type:Individual
Prefix:
First Name:LESLEE
Middle Name:ELYSE
Last Name:BLANCH
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1542 E 73RD S
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7879
Mailing Address - Country:US
Mailing Address - Phone:208-529-1390
Mailing Address - Fax:
Practice Address - Street 1:1542 E 73RD S
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7879
Practice Address - Country:US
Practice Address - Phone:208-529-1390
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-24
Last Update Date:2023-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDD-944133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered