Provider Demographics
NPI:1053828145
Name:LEIST, ANGELIQUE MARIE
Entity Type:Individual
Prefix:
First Name:ANGELIQUE
Middle Name:MARIE
Last Name:LEIST
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3103 BRECKENRIDGE LN STE 1
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40220-2798
Mailing Address - Country:US
Mailing Address - Phone:501-495-5055
Mailing Address - Fax:502-495-5057
Practice Address - Street 1:3103 BRECKENRIDGE LN STE 1
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40220
Practice Address - Country:US
Practice Address - Phone:501-495-5055
Practice Address - Fax:502-495-5057
Is Sole Proprietor?:No
Enumeration Date:2018-01-10
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012004363LF0000X
KY1146850163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse