Provider Demographics
NPI:1275619710
Name:STEWART, LESLIE DATZ (CNM)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:DATZ
Last Name:STEWART
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1071 S LUCERNE BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90019-6812
Mailing Address - Country:US
Mailing Address - Phone:323-932-1823
Mailing Address - Fax:818-760-6542
Practice Address - Street 1:1071 S LUCERNE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90019-6812
Practice Address - Country:US
Practice Address - Phone:323-932-1823
Practice Address - Fax:818-760-6542
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-27
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANMW242367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANMW002420Medicaid