Provider Demographics
NPI:1013126135
Name:LODER, LESLEY LAUREN (NP)
Entity Type:Individual
Prefix:
First Name:LESLEY
Middle Name:LAUREN
Last Name:LODER
Suffix:
Gender:F
Credentials:NP
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 890041
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-0041
Mailing Address - Country:US
Mailing Address - Phone:828-326-3809
Mailing Address - Fax:828-326-3371
Practice Address - Street 1:810 FAIRGROVE CHURCH RD
Practice Address - Street 2:
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28602-9617
Practice Address - Country:US
Practice Address - Phone:828-326-3809
Practice Address - Fax:828-326-3371
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC182872363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7004482Medicaid
NC8052895Medicaid
NC182872OtherNC-RN LICENSE
NC7004482Medicaid