Provider Demographics
NPI:1497139836
Name:REYNOLDS, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:REYNOLDS
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 1:2358 UNIVERSITY AVE # 639
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-2720
Mailing Address - Country:US
Mailing Address - Phone:619-408-4680
Mailing Address - Fax:619-291-8819
Practice Address - Street 1:4077 MENLO AVE APT 4
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-1945
Practice Address - Country:US
Practice Address - Phone:619-408-4680
Practice Address - Fax:619-291-8819
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN264695164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAVN264695OtherNURSING LICENSE NUMBER