Provider Demographics
NPI:1255676839
Name:CLARK, LESLIE ANN (ARNP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:CLARK
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 W COLONIAL DR
Mailing Address - Street 2:STE 386
Mailing Address - City:OCOEE
Mailing Address - State:FL
Mailing Address - Zip Code:34761-3400
Mailing Address - Country:US
Mailing Address - Phone:407-296-1990
Mailing Address - Fax:407-296-1992
Practice Address - Street 1:10000 W COLONIAL DR
Practice Address - Street 2:STE 386
Practice Address - City:OCOEE
Practice Address - State:FL
Practice Address - Zip Code:34761-3400
Practice Address - Country:US
Practice Address - Phone:407-296-1990
Practice Address - Fax:407-296-1992
Is Sole Proprietor?:No
Enumeration Date:2012-12-07
Last Update Date:2016-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 9277706363LF0000X
FLARNP9277706363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLN/AMedicaid
FLARNP9277706OtherMEDICAL LICENSE
FLGX211ZMedicare PIN