Provider Demographics
NPI:1710633110
Name:GORDON, LESLIE (FNP)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:GORDON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:NEILL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:27 COUNTY ROAD 376
Mailing Address - Street 2:
Mailing Address - City:WATER VALLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38965-3748
Mailing Address - Country:US
Mailing Address - Phone:662-931-7653
Mailing Address - Fax:
Practice Address - Street 1:2680 W OXFORD LOOP
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-5441
Practice Address - Country:US
Practice Address - Phone:662-236-6465
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-23
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSGORD-FDW4W3363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner