Provider Demographics
NPI:1225091879
Name:PHILLIPS, LESLIE MARIE (RN)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:MARIE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:MISS
Other - First Name:LESLIE
Other - Middle Name:MARIE
Other - Last Name:NORTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:PO BOX 26617
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76126-9998
Mailing Address - Country:US
Mailing Address - Phone:817-800-8386
Mailing Address - Fax:817-295-4992
Practice Address - Street 1:10017 STONELEIGH DR
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76126
Practice Address - Country:US
Practice Address - Phone:817-800-8386
Practice Address - Fax:817-295-4992
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX232148163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0079KEOtherBCBS OF TEXAS PROVIDER #