Healthcare Provider Details

I. General information

NPI: 1578687695
Provider Name (Legal Business Name): PATRICIA CAROL LEISTMAN MS, RD, CDN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 MINEOLA BOULEVARD SUITE 210
MINEOLA NY
11501
US

IV. Provider business mailing address

222 STATION PLAZA NORTH SUITE 611
MINEOLA NY
11501
US

V. Phone/Fax

Practice location:
  • Phone: 516-663-4600
  • Fax: 516-663-3070
Mailing address:
  • Phone: 516-663-2532
  • Fax: 516-663-2233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number001517
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number001517
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: