Provider Demographics
NPI:1427368588
Name:NUSSBAUM, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:NUSSBAUM
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 1:101 W. MUHAMMAD ALI
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1451
Mailing Address - Country:US
Mailing Address - Phone:502-589-6000
Mailing Address - Fax:502-589-8771
Practice Address - Street 1:3503 POPLAR LEVEL RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-1009
Practice Address - Country:US
Practice Address - Phone:502-589-8600
Practice Address - Fax:502-589-8771
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2011-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker