Provider Demographics
NPI:1285059907
Name:DUDLEY, LEIGH ELLEN LASTER (MS, RDN, LDN)
Entity type:Individual
Prefix:MRS
First Name:LEIGH ELLEN
Middle Name:LASTER
Last Name:DUDLEY
Suffix:
Gender:F
Credentials:MS, RDN, LDN
Other - Prefix:
Other - First Name:LEIGH ELLEN
Other - Middle Name:RUTH
Other - Last Name:LASTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1029 WISHING WELL LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28270-2152
Mailing Address - Country:US
Mailing Address - Phone:704-451-7401
Mailing Address - Fax:
Practice Address - Street 1:1029 WISHING WELL LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28270-2152
Practice Address - Country:US
Practice Address - Phone:704-451-7401
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-04
Last Update Date:2015-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3568133N00000X, 133V00000X
NCL004527133V00000X, 133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No133N00000XDietary & Nutritional Service ProvidersNutritionist