Provider Demographics
NPI:1295847325
Name:NYSTUEN, LESLIE ANN (MD)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:ANN
Last Name:NYSTUEN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:548 LEBANON STREET
Mailing Address - Street 2:
Mailing Address - City:MELROSE
Mailing Address - State:MA
Mailing Address - Zip Code:02176
Mailing Address - Country:US
Mailing Address - Phone:781-665-4364
Mailing Address - Fax:781-662-2284
Practice Address - Street 1:548 LEBANON STREET
Practice Address - Street 2:
Practice Address - City:MELROSE
Practice Address - State:MA
Practice Address - Zip Code:02176
Practice Address - Country:US
Practice Address - Phone:781-665-4364
Practice Address - Fax:781-662-2284
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2011-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA80019208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA9787119Medicaid
MA9787119Medicaid