Provider Demographics
NPI:1013600915
Name:LESLIE, GRACE
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:LESLIE
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 1:133 HOSPITAL DR STE 500
Mailing Address - Street 2:
Mailing Address - City:CARTHAGE
Mailing Address - State:TN
Mailing Address - Zip Code:37030-4020
Mailing Address - Country:US
Mailing Address - Phone:615-735-0700
Mailing Address - Fax:
Practice Address - Street 1:133 HOSPITAL DR STE 500
Practice Address - Street 2:
Practice Address - City:CARTHAGE
Practice Address - State:TN
Practice Address - Zip Code:37030-4020
Practice Address - Country:US
Practice Address - Phone:615-735-0700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-29
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN6173363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program