Provider Demographics
NPI:1124023916
Name:VAN DYKE, LESLIE POLK (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:POLK
Last Name:VAN DYKE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:P
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:ARNP
Mailing Address - Street 1:10512 S 87TH EAST AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74133-7067
Mailing Address - Country:US
Mailing Address - Phone:903-504-3376
Mailing Address - Fax:
Practice Address - Street 1:1658 W GRANDE BLVD
Practice Address - Street 2:STE 100
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75703-4426
Practice Address - Country:US
Practice Address - Phone:903-617-6239
Practice Address - Fax:903-617-6249
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2021-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-45551-051163W00000X
TX648664363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8772NAOtherBCBS
KS200253540AMedicaid
KS200253540AMedicaid
TX8772NAOtherBCBS