Provider Demographics
NPI:1922774405
Name:OWENS, LESLIE (IBCLC)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:OWENS
Suffix:
Gender:F
Credentials:IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1794 SEPTEMBER WAY
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-1192
Mailing Address - Country:US
Mailing Address - Phone:423-557-9759
Mailing Address - Fax:
Practice Address - Street 1:1794 SEPTEMBER WAY
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-1192
Practice Address - Country:US
Practice Address - Phone:423-557-9759
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-17
Last Update Date:2022-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
247ZC0005X
GALC000210163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant
No247ZC0005XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyClinical Laboratory Director, Non-physician