Provider Demographics
NPI:1417376591
Name:LESIAK, TARA
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:
Last Name:LESIAK
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 1:1804 S EDDY ST
Mailing Address - Street 2:
Mailing Address - City:GRAND ISLAND
Mailing Address - State:NE
Mailing Address - Zip Code:68801-7114
Mailing Address - Country:US
Mailing Address - Phone:308-384-7896
Mailing Address - Fax:308-384-9231
Practice Address - Street 1:1804 S EDDY ST
Practice Address - Street 2:
Practice Address - City:GRAND ISLAND
Practice Address - State:NE
Practice Address - Zip Code:68801-7114
Practice Address - Country:US
Practice Address - Phone:308-384-7896
Practice Address - Fax:308-384-9231
Is Sole Proprietor?:No
Enumeration Date:2014-04-15
Last Update Date:2014-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE470522836Medicaid