Basic Information
| Provider Information | |||||||||
| NPI: | 1437401031 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEONG | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RD, CDE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JUE | ||||||||
| OtherFirstName: | MARY | ||||||||
| OtherMiddleName: | GRACE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2710 MIDDLEFIELD RD | ||||||||
| Address2: | |||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940633404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505787141 | ||||||||
| FaxNumber: | 6503664732 | ||||||||
| Practice Location | |||||||||
| Address1: | 2710 MIDDLEFIELD RD | ||||||||
| Address2: | |||||||||
| City: | REDWOOD CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940633404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6505787141 | ||||||||
| FaxNumber: | 6503664732 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/05/2012 | ||||||||
| LastUpdateDate: | 06/16/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 133V00000X | 706151 | Y | Dietary & Nutritional Service Providers | Dietitian, Registered |
No ID Information.