Provider Demographics
NPI:1851896260
Name:PHILLIPS, LESLIE MICHELE (NP)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:MICHELE
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:MICHELE
Other - Last Name:DEFORD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2605 N LEBANON ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:IN
Mailing Address - Zip Code:46052-1476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2705 N LEBANON ST STE 300
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:IN
Practice Address - Zip Code:46052
Practice Address - Country:US
Practice Address - Phone:765-485-8649
Practice Address - Fax:765-485-8650
Is Sole Proprietor?:No
Enumeration Date:2018-03-27
Last Update Date:2023-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28215572A163W00000X
IN71007944A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300013177Medicaid