Provider Demographics
NPI:1134991185
Name:LILLY, LESLEY NICOLE (MS, RDN, LD, IFNCP)
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:NICOLE
Last Name:LILLY
Suffix:
Gender:F
Credentials:MS, RDN, LD, IFNCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:109 E RIDGEWOOD CT # 109
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-2341
Mailing Address - Country:US
Mailing Address - Phone:210-722-6929
Mailing Address - Fax:
Practice Address - Street 1:109 E RIDGEWOOD CT # 109
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-2341
Practice Address - Country:US
Practice Address - Phone:210-722-6929
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-10-24
Last Update Date:2023-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT85977133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered