Provider Demographics
NPI:1033655519
Name:STAVIG, LESLIE (RN)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:STAVIG
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:608 38TH ST
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:CA
Mailing Address - Zip Code:94805-1702
Mailing Address - Country:US
Mailing Address - Phone:510-215-8726
Mailing Address - Fax:
Practice Address - Street 1:386 14TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-3211
Practice Address - Country:US
Practice Address - Phone:510-210-5056
Practice Address - Fax:510-533-2199
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-09
Last Update Date:2017-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA535172163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse