Healthcare Provider Details

I. General information

NPI: 1760685663
Provider Name (Legal Business Name): MARY E LESLIE NUTRITIONIST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2012 S VICTORIA AVE
LOS ANGELES CA
90016-1814
US

IV. Provider business mailing address

2012 S VICTORIA AVE
LOS ANGELES CA
90016-1814
US

V. Phone/Fax

Practice location:
  • Phone: 626-590-6461
  • Fax:
Mailing address:
  • Phone: 626-590-6461
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: