Provider Demographics
NPI:1598005654
Name:PHELPS, LESLIE GAYLE (ANCC)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:GAYLE
Last Name:PHELPS
Suffix:
Gender:F
Credentials:ANCC
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:GAYLE
Other - Last Name:JAYNES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:PO BOX 2634
Mailing Address - Street 2:
Mailing Address - City:CORBIN
Mailing Address - State:KY
Mailing Address - Zip Code:40702-2634
Mailing Address - Country:US
Mailing Address - Phone:606-280-4000
Mailing Address - Fax:606-280-4051
Practice Address - Street 1:1013 MASTER ST
Practice Address - Street 2:
Practice Address - City:CORBIN
Practice Address - State:KY
Practice Address - Zip Code:40701-1065
Practice Address - Country:US
Practice Address - Phone:606-280-4000
Practice Address - Fax:606-280-4051
Is Sole Proprietor?:Yes
Enumeration Date:2013-02-26
Last Update Date:2021-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007920363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100243140Medicaid