Provider Demographics
NPI:1730102989
Name:LESLIE, MARYANN (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:MARYANN
Middle Name:
Last Name:LESLIE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 KINGSLEY AVENUE
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073
Mailing Address - Country:US
Mailing Address - Phone:904-276-0001
Mailing Address - Fax:904-276-5333
Practice Address - Street 1:2100 KINGSLEY AVENUE
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073
Practice Address - Country:US
Practice Address - Phone:904-276-0001
Practice Address - Fax:904-276-5333
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3343402363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00852111OtherRAILROAD MEDICARE
U6384ZMedicare ID - Type Unspecified
FLP00852111OtherRAILROAD MEDICARE