Provider Demographics
NPI:1467571109
Name:PRYOR, LESLIE R (RN,MSN,ANP-C)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:R
Last Name:PRYOR
Suffix:
Gender:F
Credentials:RN,MSN,ANP-C
Other - Prefix:
Other - First Name:PRACTITIONER
Other - Middle Name:
Other - Last Name:PRYOR
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MSN CNP
Mailing Address - Street 1:777 ROUTE 70 EAST
Mailing Address - Street 2:SUITE G-101
Mailing Address - City:MARLTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08053-2345
Mailing Address - Country:US
Mailing Address - Phone:856-983-9939
Mailing Address - Fax:856-983-9936
Practice Address - Street 1:777 ROUTE 70 EAST
Practice Address - Street 2:SUITE G-101
Practice Address - City:MARLTON
Practice Address - State:NJ
Practice Address - Zip Code:08053-2345
Practice Address - Country:US
Practice Address - Phone:856-983-9939
Practice Address - Fax:856-983-9936
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2014-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNN59248363LA2200X
NJ26NN05924800363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ099627TLGMedicare UPIN