Provider Demographics
NPI:1477878221
Name:MARSHALL, LESLIE ANN (DO)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:ANN
Last Name:MARSHALL
Suffix:
Gender:F
Credentials:DO
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 1100
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-1100
Mailing Address - Country:US
Mailing Address - Phone:417-256-9111
Mailing Address - Fax:417-257-5947
Practice Address - Street 1:1115 ALASKA ST STE 214
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-2014
Practice Address - Country:US
Practice Address - Phone:417-505-7114
Practice Address - Fax:417-853-5302
Is Sole Proprietor?:Yes
Enumeration Date:2010-04-05
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2015018546207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200062024Medicaid