Provider Demographics
NPI:1336469469
Name:LOCKLEAR, LESLIE AMANDA (FNP-C)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:AMANDA
Last Name:LOCKLEAR
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:WHEELESS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1115 SE 164TH AVE DEPT 358
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98683-8004
Mailing Address - Country:US
Mailing Address - Phone:360-729-1462
Mailing Address - Fax:360-729-3104
Practice Address - Street 1:3100 TONGASS AVE
Practice Address - Street 2:
Practice Address - City:KETCHIKAN
Practice Address - State:AK
Practice Address - Zip Code:99901-5746
Practice Address - Country:US
Practice Address - Phone:907-228-8140
Practice Address - Fax:907-228-8440
Is Sole Proprietor?:No
Enumeration Date:2010-06-11
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK1146363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1022353Medicaid