Provider Demographics
NPI:1265794663
Name:TATUM, LESLEE A (NP)
Entity type:Individual
Prefix:
First Name:LESLEE
Middle Name:A
Last Name:TATUM
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:LESLEE
Other - Middle Name:A
Other - Last Name:KAPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:888-484-3258
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28164251A363L00000X
IN71004032A363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001341106OtherANTHEM PTAN
IN000000844568OtherANTHEM PTAN
IN000000864048OtherANTHEM PTAN
IN000000806999OtherANTHEM PTAN
INQ00013262OtherRAILROAD PTAN
IN1102230356OtherANTHEM PTAN
IN201135070Medicaid