Provider Demographics
NPI:1639130560
Name:CARLSON, LESLIE ANN (NP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:CARLSON
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 1:126 S. MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:MT
Mailing Address - Zip Code:59047-2624
Mailing Address - Country:US
Mailing Address - Phone:406-222-1111
Mailing Address - Fax:406-823-6305
Practice Address - Street 1:100 BEAVERHEAD TRAIL
Practice Address - Street 2:
Practice Address - City:BIG SKY
Practice Address - State:MT
Practice Address - Zip Code:59716-0000
Practice Address - Country:US
Practice Address - Phone:406-995-6650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-30
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN0985222163W00000X
MT32326363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT307513Medicaid
P65914Medicare UPIN