Provider Demographics
NPI:1639643687
Name:HAUCK, LESLEY RAE (RN)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:RAE
Last Name:HAUCK
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 S MAIN ST STE 150-54
Mailing Address - Street 2:
Mailing Address - City:KELLER
Mailing Address - State:TX
Mailing Address - Zip Code:76248-7043
Mailing Address - Country:US
Mailing Address - Phone:703-593-2619
Mailing Address - Fax:
Practice Address - Street 1:5301 SUGARLOAF TRL # 5208
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76244-1437
Practice Address - Country:US
Practice Address - Phone:703-593-2619
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-13
Last Update Date:2019-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies