Provider Demographics
NPI:1073021556
Name:FISHER, LESLYE GWEN (FNP)
Entity Type:Individual
Prefix:
First Name:LESLYE
Middle Name:GWEN
Last Name:FISHER
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:362 W 15TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-2266
Practice Address - Country:US
Practice Address - Phone:317-948-5450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-01-18
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28195315A163WN0800X
IN71008072A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WN0800XNursing Service ProvidersRegistered NurseNeuroscience
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300016348Medicaid
IN262210037OtherMEDICARE PTAN