Provider Demographics
NPI:1124603154
Name:OTT, LESLEY REVIERE (NP)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:REVIERE
Last Name:OTT
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12581 THREE LAKES DR
Mailing Address - Street 2:
Mailing Address - City:WALKER
Mailing Address - State:LA
Mailing Address - Zip Code:70785-8214
Mailing Address - Country:US
Mailing Address - Phone:337-580-2064
Mailing Address - Fax:
Practice Address - Street 1:6411 PERKINS RD STE 100
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-4125
Practice Address - Country:US
Practice Address - Phone:225-303-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-11
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA218811363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily