Provider Demographics
NPI:1598077398
Name:OGILVY, LESLIE JEAN (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:JEAN
Last Name:OGILVY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:LESLIE
Other - Middle Name:JEAN
Other - Last Name:MALAY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:1524 LAFAYETTE PKWY
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-2566
Mailing Address - Country:US
Mailing Address - Phone:706-530-2151
Mailing Address - Fax:770-460-6610
Practice Address - Street 1:1524 LAFAYETTE PKWY
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-2566
Practice Address - Country:US
Practice Address - Phone:706-530-2151
Practice Address - Fax:770-460-6610
Is Sole Proprietor?:No
Enumeration Date:2010-07-08
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004937207R00000X, 363A00000X
GA9261363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COPA.0004937OtherMEDICAL LICENSE
CO9000158036Medicaid
CO9000158036Medicaid