Provider Demographics
NPI:1689147456
Name:FITZGIBBON, LESLIE ROBERSON (NP-C)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ROBERSON
Last Name:FITZGIBBON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:RENI
Other - Middle Name:
Other - Last Name:FITZGIBBON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP-C
Mailing Address - Street 1:9500 CLAREMONT AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87112-1342
Mailing Address - Country:US
Mailing Address - Phone:505-659-1649
Mailing Address - Fax:
Practice Address - Street 1:9500 CLAREMONT AVE NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87112-1342
Practice Address - Country:US
Practice Address - Phone:505-659-1649
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM54898363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily