Provider Demographics
NPI:1447591821
Name:CORNWELL, LESLIE ANN (CNM)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:CORNWELL
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:ANN
Other - Last Name:FEIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:36650 GRAND RIVER AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:MI
Mailing Address - Zip Code:48335-2919
Mailing Address - Country:US
Mailing Address - Phone:734-691-0980
Mailing Address - Fax:989-607-1986
Practice Address - Street 1:36650 GRAND RIVER AVE STE 101
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:MI
Practice Address - Zip Code:48335-2919
Practice Address - Country:US
Practice Address - Phone:734-691-0980
Practice Address - Fax:989-607-1986
Is Sole Proprietor?:No
Enumeration Date:2013-03-08
Last Update Date:2024-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704266822176B00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300007978Medicaid
IN236040250OtherMEDICARE PTAN