Provider Demographics
NPI:1922502319
Name:OGBEBOR, LESLIE
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:OGBEBOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 688
Mailing Address - Street 2:
Mailing Address - City:JESSUP
Mailing Address - State:MD
Mailing Address - Zip Code:20794-0688
Mailing Address - Country:US
Mailing Address - Phone:301-592-7642
Mailing Address - Fax:
Practice Address - Street 1:6701 N CHARLES ST
Practice Address - Street 2:
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21204-6808
Practice Address - Country:US
Practice Address - Phone:443-849-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-20
Last Update Date:2019-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR196101363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care