Provider Demographics
NPI:1376793349
Name:ALLEN, LESLEY JO (APRN)
Entity Type:Individual
Prefix:MS
First Name:LESLEY
Middle Name:JO
Last Name:ALLEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:LESLEY
Other - Middle Name:
Other - Last Name:BROCK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:560 S LOOP RD
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:41017-3405
Mailing Address - Country:US
Mailing Address - Phone:859-301-2663
Mailing Address - Fax:859-301-0655
Practice Address - Street 1:560 S LOOP RD
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:KY
Practice Address - Zip Code:41017-3405
Practice Address - Country:US
Practice Address - Phone:859-301-2663
Practice Address - Fax:859-301-0655
Is Sole Proprietor?:No
Enumeration Date:2008-09-25
Last Update Date:2015-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA.10389-NP363LF0000X
KY3005659363LF0000X
KY1098471163W00000X
OHRN.290334-COA1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100098260Medicaid
KYK115600Medicare PIN