Provider Demographics
NPI:1194035899
Name:PETERSON, LESLIEANN LAUREN
Entity Type:Individual
Prefix:MRS
First Name:LESLIEANN
Middle Name:LAUREN
Last Name:PETERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9506
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07104-0506
Mailing Address - Country:US
Mailing Address - Phone:973-318-8316
Mailing Address - Fax:973-318-8317
Practice Address - Street 1:544 BROADWAY
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07104
Practice Address - Country:US
Practice Address - Phone:973-318-8316
Practice Address - Fax:973-318-8317
Is Sole Proprietor?:No
Enumeration Date:2010-10-14
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY613612163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health