Provider Demographics
NPI:1912202722
Name:LEONARD, KELLY SUE (NUTRITIONIST)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:SUE
Last Name:LEONARD
Suffix:
Gender:
Credentials:NUTRITIONIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2801 BLUE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-0114
Mailing Address - Country:US
Mailing Address - Phone:984-974-0502
Mailing Address - Fax:984-974-9579
Practice Address - Street 1:2801 BLUE RIDGE RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-0114
Practice Address - Country:US
Practice Address - Phone:984-974-0502
Practice Address - Fax:984-974-9579
Is Sole Proprietor?:No
Enumeration Date:2011-01-26
Last Update Date:2025-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA969608133VN1004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133VN1004XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004909976Medicaid