Provider Demographics
NPI:1336789114
Name:COLLINS, LESLIE ANN
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANN
Last Name:COLLINS
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 1:13465 CONVOY RD
Mailing Address - Street 2:
Mailing Address - City:VAN WERT
Mailing Address - State:OH
Mailing Address - Zip Code:45891-8733
Mailing Address - Country:US
Mailing Address - Phone:419-860-0494
Mailing Address - Fax:
Practice Address - Street 1:539 N MAIN ST
Practice Address - Street 2:
Practice Address - City:CONVOY
Practice Address - State:OH
Practice Address - Zip Code:45832-7737
Practice Address - Country:US
Practice Address - Phone:419-860-0494
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-09
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251E00000XAgenciesHome Health
No376J00000XNursing Service Related ProvidersHomemaker
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0377215Medicaid