Provider Demographics
NPI:1598247892
Name:WILSON, LESLIE HENRY
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:HENRY
Last Name:WILSON
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 1:1211 N RANGE AVE STE D
Mailing Address - Street 2:
Mailing Address - City:DENHAM SPRINGS
Mailing Address - State:LA
Mailing Address - Zip Code:70726-2428
Mailing Address - Country:US
Mailing Address - Phone:225-667-4999
Mailing Address - Fax:225-667-4998
Practice Address - Street 1:1211 N RANGE AVE STE D
Practice Address - Street 2:
Practice Address - City:DENHAM SPRINGS
Practice Address - State:LA
Practice Address - Zip Code:70726-2428
Practice Address - Country:US
Practice Address - Phone:225-667-4999
Practice Address - Fax:225-667-4998
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-04
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA15462253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA463446046Medicaid