Provider Demographics
NPI:1194950493
Name:GONCALVES, LEANNE ELAINE (RD,LD)
Entity type:Individual
Prefix:
First Name:LEANNE
Middle Name:ELAINE
Last Name:GONCALVES
Suffix:
Gender:F
Credentials:RD,LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4365 COUNTY ROAD 24
Mailing Address - Street 2:
Mailing Address - City:MOUNT GILEAD
Mailing Address - State:OH
Mailing Address - Zip Code:43338-9597
Mailing Address - Country:US
Mailing Address - Phone:419-560-5097
Mailing Address - Fax:419-946-3408
Practice Address - Street 1:4365 COUNTY ROAD 24
Practice Address - Street 2:
Practice Address - City:MOUNT GILEAD
Practice Address - State:OH
Practice Address - Zip Code:43338-9597
Practice Address - Country:US
Practice Address - Phone:419-560-5097
Practice Address - Fax:419-946-3408
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-16
Last Update Date:2009-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD 1244133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered