Provider Demographics
NPI:1104041755
Name:DAVIS, LESLIE J (NP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:J
Last Name:DAVIS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:PAIGE
Other - Middle Name:JORDAN
Other - Last Name:KINSLEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3431 WALKERTOWN COMMONS DR
Practice Address - Street 2:
Practice Address - City:WALKERTOWN
Practice Address - State:NC
Practice Address - Zip Code:27051-9152
Practice Address - Country:US
Practice Address - Phone:336-564-4101
Practice Address - Fax:336-595-2035
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2021-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004872363L00000X
TN12521363L00000X
NC139414363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7004567Medicaid