Provider Demographics
NPI:1790430940
Name:MILLER, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:MILLER
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 1:910 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-4322
Mailing Address - Country:US
Mailing Address - Phone:870-881-4607
Mailing Address - Fax:
Practice Address - Street 1:910 LIBERTY ST
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-4322
Practice Address - Country:US
Practice Address - Phone:870-881-4607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-16
Last Update Date:2022-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARLO44435164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse