Provider Demographics
NPI:1871191940
Name:UMPLEBY, LESLIE ANN (QSP)
Entity Type:Individual
Prefix:MS
First Name:LESLIE
Middle Name:ANN
Last Name:UMPLEBY
Suffix:
Gender:F
Credentials:QSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1919 KYLE LN NW APT 43
Mailing Address - Street 2:
Mailing Address - City:MANDAN
Mailing Address - State:ND
Mailing Address - Zip Code:58554-1495
Mailing Address - Country:US
Mailing Address - Phone:701-204-5407
Mailing Address - Fax:
Practice Address - Street 1:300 6TH AVE SW
Practice Address - Street 2:
Practice Address - City:MANDAN
Practice Address - State:ND
Practice Address - Zip Code:58554-4013
Practice Address - Country:US
Practice Address - Phone:701-663-6253
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-12
Last Update Date:2020-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND14765423747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND1476542Medicaid