Provider Demographics
NPI:1376940635
Name:CHARLES, LESLEY NICOLE
Entity Type:Individual
Prefix:MRS
First Name:LESLEY
Middle Name:NICOLE
Last Name:CHARLES
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 1:400 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRANFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06405-3416
Mailing Address - Country:US
Mailing Address - Phone:203-483-7778
Mailing Address - Fax:203-481-0234
Practice Address - Street 1:400 W MAIN ST
Practice Address - Street 2:
Practice Address - City:BRANFORD
Practice Address - State:CT
Practice Address - Zip Code:06405-3416
Practice Address - Country:US
Practice Address - Phone:203-483-7778
Practice Address - Fax:203-481-0234
Is Sole Proprietor?:No
Enumeration Date:2014-12-01
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT5995363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008057120Medicaid
D400341176Medicare PIN