Provider Demographics
NPI:1922465111
Name:PANNUCCI, LESLIE (PT)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:PANNUCCI
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:GOLDMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9722 MOUNT TABOR RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21769-9523
Mailing Address - Country:US
Mailing Address - Phone:240-490-8093
Mailing Address - Fax:240-490-8095
Practice Address - Street 1:4707 SCHLEY AVE UNIT 595F
Practice Address - Street 2:
Practice Address - City:BRADDOCK HEIGHTS
Practice Address - State:MD
Practice Address - Zip Code:21714-7524
Practice Address - Country:US
Practice Address - Phone:240-490-8093
Practice Address - Fax:240-490-8095
Is Sole Proprietor?:No
Enumeration Date:2016-01-20
Last Update Date:2016-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD21752225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist