Provider Demographics
NPI:1265660427
Name:WALCOTT, LESLIE R (LPN)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:R
Last Name:WALCOTT
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MRS
Other - First Name:LESLIE
Other - Middle Name:R
Other - Last Name:WALCOTT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LPN
Mailing Address - Street 1:4 CHEN CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLE ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:11953-1901
Mailing Address - Country:US
Mailing Address - Phone:631-258-2930
Mailing Address - Fax:
Practice Address - Street 1:4 CHEN CT
Practice Address - Street 2:
Practice Address - City:MIDDLE ISLAND
Practice Address - State:NY
Practice Address - Zip Code:11953-1901
Practice Address - Country:US
Practice Address - Phone:631-258-2930
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-26
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2688221164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse