Provider Demographics
NPI:1629423413
Name:KLOCK, LESLEY JORGENSEN (FNP-C)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:JORGENSEN
Last Name:KLOCK
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:LESLEY
Other - Middle Name:KIRSTEN
Other - Last Name:JORGENSEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:374 W CITATION LN
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-1358
Mailing Address - Country:US
Mailing Address - Phone:480-707-3284
Mailing Address - Fax:
Practice Address - Street 1:4430 E RAY RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-6092
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-28
Last Update Date:2016-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP8476363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily