Provider Demographics
NPI:1043380777
Name:MILLS, LESLIE CAROL (RN, CPNP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:CAROL
Last Name:MILLS
Suffix:
Gender:F
Credentials:RN, CPNP
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:CAROL
Other - Last Name:MEDFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, CPNP
Mailing Address - Street 1:411 TOWN PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:EVANS
Mailing Address - State:GA
Mailing Address - Zip Code:30809-3487
Mailing Address - Country:US
Mailing Address - Phone:706-854-2500
Mailing Address - Fax:706-854-2559
Practice Address - Street 1:1303 DANTIGNAC ST STE 2600
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2796
Practice Address - Country:US
Practice Address - Phone:706-854-2500
Practice Address - Fax:706-854-2559
Is Sole Proprietor?:No
Enumeration Date:2006-11-09
Last Update Date:2024-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN077228208000000X, 363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000823611EOtherMEDICAID EVANS
GA000823611DOtherMEDICAID POB4