Provider Demographics
NPI:1891920153
Name:STALLCUP, LESLIE RYAN (BA MHPP)
Entity Type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:RYAN
Last Name:STALLCUP
Suffix:
Gender:F
Credentials:BA MHPP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1805 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:PARAGOULD
Mailing Address - State:AR
Mailing Address - Zip Code:72450-4075
Mailing Address - Country:US
Mailing Address - Phone:870-215-2710
Mailing Address - Fax:
Practice Address - Street 1:1910 RECTOR RD
Practice Address - Street 2:
Practice Address - City:PARAGOULD
Practice Address - State:AR
Practice Address - Zip Code:72450-2004
Practice Address - Country:US
Practice Address - Phone:870-240-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-15
Last Update Date:2009-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist