Provider Demographics
NPI:1316005770
Name:HOLTKE, LESLIE NICOLLE (CNP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:NICOLLE
Last Name:HOLTKE
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 KETTERING BLVD BLDG B3
Mailing Address - Street 2:
Mailing Address - City:MORAINE
Mailing Address - State:OH
Mailing Address - Zip Code:45439-1924
Mailing Address - Country:US
Mailing Address - Phone:937-991-3188
Mailing Address - Fax:937-223-9811
Practice Address - Street 1:2350 MIAMI VALLEY DR
Practice Address - Street 2:SUITE 530
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45459-4778
Practice Address - Country:US
Practice Address - Phone:937-435-3546
Practice Address - Fax:937-435-3568
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP-09088363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2712756Medicaid
OH2712756Medicaid
HONP22271Medicare PIN
HONP22272Medicare PIN