Provider Demographics
NPI:1881231538
Name:EVANS, LESLIE BROOKE (FNP-C)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:BROOKE
Last Name:EVANS
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:667 GRIFFIN CEMETERY RD
Mailing Address - Street 2:
Mailing Address - City:AMBROSE
Mailing Address - State:GA
Mailing Address - Zip Code:31512-3832
Mailing Address - Country:US
Mailing Address - Phone:912-389-6279
Mailing Address - Fax:
Practice Address - Street 1:906 BRYAN ST W
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2330
Practice Address - Country:US
Practice Address - Phone:912-383-9300
Practice Address - Fax:912-383-9292
Is Sole Proprietor?:No
Enumeration Date:2019-12-02
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN224154363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily