Provider Demographics
NPI:1093975526
Name:MILLER, LESLIE LYNN (RN)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:LYNN
Last Name:MILLER
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:LYNN
Other - Last Name:CLIFTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3355 DOUGLAS RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1781
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:325 N LAFAYETTE BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46601-1208
Practice Address - Country:US
Practice Address - Phone:574-647-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28141521A163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200424820Medicaid