Healthcare Provider Details

I. General information

NPI: 1225307325
Provider Name (Legal Business Name): LESLIE CLEM EDMUNDS MPH, RD, LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/19/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4359 E ENON RD
YELLOW SPRINGS OH
45387-9708
US

IV. Provider business mailing address

4549 OLD MILL RD
SPRINGFIELD OH
45502-9747
US

V. Phone/Fax

Practice location:
  • Phone: 937-206-1131
  • Fax: 937-917-8048
Mailing address:
  • Phone: 937-206-1131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1013816
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number3262
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: