Provider Demographics
NPI:1053818468
Name:MELANCON, SUSAN LEGGETT (RDN, LDN)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:LEGGETT
Last Name:MELANCON
Suffix:
Gender:F
Credentials:RDN, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 KERRY PT
Mailing Address - Street 2:
Mailing Address - City:DES ALLEMANDS
Mailing Address - State:LA
Mailing Address - Zip Code:70030-3261
Mailing Address - Country:US
Mailing Address - Phone:985-306-9003
Mailing Address - Fax:
Practice Address - Street 1:737 PAUL MAILLARD RD SUITE A-3
Practice Address - Street 2:
Practice Address - City:LULING
Practice Address - State:LA
Practice Address - Zip Code:70070-7007
Practice Address - Country:US
Practice Address - Phone:985-306-9003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-11
Last Update Date:2018-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2359133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered