Provider Demographics
NPI:1114249901
Name:ELLEDGE, LESLIE K (CRNA)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:K
Last Name:ELLEDGE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:K
Other - Last Name:DENTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1389
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35807-0389
Mailing Address - Country:US
Mailing Address - Phone:205-979-5882
Mailing Address - Fax:205-979-1248
Practice Address - Street 1:245 GOVERNORS DR SE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-2700
Practice Address - Country:US
Practice Address - Phone:205-979-5882
Practice Address - Fax:205-979-1248
Is Sole Proprietor?:No
Enumeration Date:2010-02-19
Last Update Date:2013-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-108714367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL511-03149OtherBC BS OF AL
AL1114249901OtherTRICARE
AL120355Medicaid
AL102I439935Medicare PIN