Provider Demographics
NPI:1811993074
Name:LEON, CARLY DG (MS RD CD)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:DG
Last Name:LEON
Suffix:
Gender:F
Credentials:MS RD CD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7836 W WINSTON WAY
Mailing Address - Street 2:
Mailing Address - City:FRANKLIN
Mailing Address - State:WI
Mailing Address - Zip Code:53132-9017
Mailing Address - Country:US
Mailing Address - Phone:630-254-1477
Mailing Address - Fax:
Practice Address - Street 1:7836 W WINSTON WAY
Practice Address - Street 2:
Practice Address - City:FRANKLIN
Practice Address - State:WI
Practice Address - Zip Code:53132-9017
Practice Address - Country:US
Practice Address - Phone:630-254-1477
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2025-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164-004154133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered