Provider Demographics
NPI:1346816204
Name:RICHARD, LESLEY NICOLE (MBA, MNA, CRNA)
Entity Type:Individual
Prefix:MRS
First Name:LESLEY
Middle Name:NICOLE
Last Name:RICHARD
Suffix:
Gender:F
Credentials:MBA, MNA, CRNA
Other - Prefix:
Other - First Name:LESLEY
Other - Middle Name:NICOLE
Other - Last Name:RICHARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1429 TAMARIND LN
Mailing Address - Street 2:
Mailing Address - City:CHAPIN
Mailing Address - State:SC
Mailing Address - Zip Code:29036-6324
Mailing Address - Country:US
Mailing Address - Phone:386-288-4529
Mailing Address - Fax:
Practice Address - Street 1:1910 BLANDING ST
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201-3520
Practice Address - Country:US
Practice Address - Phone:803-256-4107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-01
Last Update Date:2023-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC243523163W00000X
SC26136367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN3702Medicaid