Provider Demographics
NPI:1104394147
Name:SMITH, LESLIE (ARNP, BSN, BS, RN)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:ARNP, BSN, BS, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:YAKIMA
Mailing Address - State:WA
Mailing Address - Zip Code:98901-2875
Mailing Address - Country:US
Mailing Address - Phone:509-248-1800
Mailing Address - Fax:
Practice Address - Street 1:120 S 3RD ST
Practice Address - Street 2:
Practice Address - City:YAKIMA
Practice Address - State:WA
Practice Address - Zip Code:98901-2875
Practice Address - Country:US
Practice Address - Phone:509-248-1800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-07
Last Update Date:2023-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN60207777163W00000X
WAAP61348718363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1104394147Medicaid