Provider Demographics
NPI:1396422887
Name:PONCE BARRERA, LESLY (MCN, RD, LD)
Entity type:Individual
Prefix:
First Name:LESLY
Middle Name:
Last Name:PONCE BARRERA
Suffix:
Gender:F
Credentials:MCN, RD, LD
Other - Prefix:
Other - First Name:LESLY
Other - Middle Name:M
Other - Last Name:PONCE GONZALES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:4008 ALTOONA DR APT 107
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75233-3516
Mailing Address - Country:US
Mailing Address - Phone:832-893-7775
Mailing Address - Fax:
Practice Address - Street 1:801 CONOVER DR
Practice Address - Street 2:
Practice Address - City:GRAND PRAIRIE
Practice Address - State:TX
Practice Address - Zip Code:75051-1519
Practice Address - Country:US
Practice Address - Phone:214-266-3400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-28
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT88635133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered