Provider Demographics
NPI:1750026522
Name:COLE, LESLEY SHAWAN
Entity Type:Individual
Prefix:MRS
First Name:LESLEY
Middle Name:SHAWAN
Last Name:COLE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3080 STONE OAK DR
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-1903
Mailing Address - Country:US
Mailing Address - Phone:678-499-9834
Mailing Address - Fax:
Practice Address - Street 1:2022 FAIRBURN RD STE D
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1062
Practice Address - Country:US
Practice Address - Phone:770-942-1044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-04
Last Update Date:2022-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN230930363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care