Provider Demographics
NPI:1700217064
Name:ABBOTT, LESLIE C (FNP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:C
Last Name:ABBOTT
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1224 NE WALNUT ST # 384
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97470-2026
Mailing Address - Country:US
Mailing Address - Phone:541-391-7506
Mailing Address - Fax:541-391-7503
Practice Address - Street 1:1813 W HARVARD AVE STE 233
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-8704
Practice Address - Country:US
Practice Address - Phone:541-391-7506
Practice Address - Fax:541-391-7503
Is Sole Proprietor?:No
Enumeration Date:2013-12-11
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201394254NP-PP363LF0000X
OR201394254NP PP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR50066907Medicaid