Provider Demographics
NPI:1558338665
Name:BERLIN, LESLEE LOWDER
Entity Type:Individual
Prefix:
First Name:LESLEE
Middle Name:LOWDER
Last Name:BERLIN
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:PO BOX 6069
Mailing Address - Street 2:
Mailing Address - City:WEST COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29171-6069
Mailing Address - Country:US
Mailing Address - Phone:803-935-8292
Mailing Address - Fax:
Practice Address - Street 1:2720 SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:WEST COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29169-4810
Practice Address - Country:US
Practice Address - Phone:803-935-8292
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-07
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC52683367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN1352Medicaid
SCQ33784Medicare UPIN
SCQ33784Medicare PIN