Provider Demographics
NPI:1366849127
Name:NAKAYA, LESLIE C
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:C
Last Name:NAKAYA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2160 CLAREMONT DR
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-2321
Mailing Address - Country:US
Mailing Address - Phone:801-809-1051
Mailing Address - Fax:
Practice Address - Street 1:5979 S FASHION BLVD
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-7364
Practice Address - Country:US
Practice Address - Phone:801-263-2370
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-21
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT348267-4405363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1366849127Medicaid