Provider Demographics
NPI:1437475936
Name:WALLACE-BERMAN, LESLEY ANN (MD)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:ANN
Last Name:WALLACE-BERMAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1656 RIVERCHASE BLVD
Practice Address - Street 2:STE 3400
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-2084
Practice Address - Country:US
Practice Address - Phone:803-328-6281
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-09
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2013-00265208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC376505Medicaid