Provider Demographics
NPI:1043744295
Name:IVORY, LESLIE (CSA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:IVORY
Suffix:
Gender:F
Credentials:CSA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5670 PEACHTREE DUNWOODY RD
Mailing Address - Street 2:SUITE 820
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1699
Mailing Address - Country:US
Mailing Address - Phone:404-851-1998
Mailing Address - Fax:404-531-4039
Practice Address - Street 1:5670 PEACHTREE DUNWOODY RD
Practice Address - Street 2:SUITE 820
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1699
Practice Address - Country:US
Practice Address - Phone:404-851-1998
Practice Address - Fax:404-531-4039
Is Sole Proprietor?:No
Enumeration Date:2017-04-14
Last Update Date:2017-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA2652246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant