Provider Demographics
NPI:1508138033
Name:MOFRAD, LESLIE MARIE (RN , MSN, CPNP)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:MARIE
Last Name:MOFRAD
Suffix:
Gender:F
Credentials:RN , MSN, CPNP
Other - Prefix:MS
Other - First Name:LESLIE
Other - Middle Name:MARIE
Other - Last Name:CAMPO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, MSN, CPNP
Mailing Address - Street 1:2331 MONROE ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-3009
Mailing Address - Country:US
Mailing Address - Phone:313-792-0345
Mailing Address - Fax:313-792-0346
Practice Address - Street 1:2331 MONROE ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-3009
Practice Address - Country:US
Practice Address - Phone:313-792-0345
Practice Address - Fax:313-792-0346
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-30
Last Update Date:2012-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704201928363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics