Provider Demographics
NPI:1598112773
Name:LESLIE, STEFFANIE (MD)
Entity Type:Individual
Prefix:
First Name:STEFFANIE
Middle Name:
Last Name:LESLIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:645 GRADELLE AVE
Mailing Address - Street 2:
Mailing Address - City:FAIRBANKS
Mailing Address - State:AK
Mailing Address - Zip Code:99709-3529
Mailing Address - Country:US
Mailing Address - Phone:907-750-1076
Mailing Address - Fax:
Practice Address - Street 1:1606 23RD AVE
Practice Address - Street 2:
Practice Address - City:FAIRBANKS
Practice Address - State:AK
Practice Address - Zip Code:99701-6407
Practice Address - Country:US
Practice Address - Phone:907-457-4567
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-18
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AK182434207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program