Provider Demographics
NPI:1528110863
Name:LEO, EVELYN THERESA (RD,LD,CDE)
Entity type:Individual
Prefix:MS
First Name:EVELYN
Middle Name:THERESA
Last Name:LEO
Suffix:
Gender:F
Credentials:RD,LD,CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:3444 BROXTON MILL WAY
Mailing Address - Street 2:
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30039-4441
Mailing Address - Country:US
Mailing Address - Phone:678-344-6930
Mailing Address - Fax:770-674-1871
Practice Address - Street 1:1462 MONTREAL RD
Practice Address - Street 2:SUITE 203
Practice Address - City:TUCKER
Practice Address - State:GA
Practice Address - Zip Code:30084-6929
Practice Address - Country:US
Practice Address - Phone:678-527-0800
Practice Address - Fax:770-674-1871
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2007-10-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA001734133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA71BBBVNMedicare PIN