Provider Demographics
NPI:1619516465
Name:WALDO, LESLIE ANN (NP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:WALDO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11109 PARKVIEW PLAZA DR # 117
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-1701
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3909 NEW VISION DR
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-1725
Practice Address - Country:US
Practice Address - Phone:260-469-6610
Practice Address - Fax:260-969-3065
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-26
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71009644A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71009644AOtherAPRN
IN71009644BOtherCSR-PRESCRIPTIVE AUTHORITY