Provider Demographics
NPI:1639163199
Name:GUSTAFSON, LESLEY A (CNM)
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:A
Last Name:GUSTAFSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:LESLEY
Other - Middle Name:A
Other - Last Name:NEGO-GUSTAFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM
Mailing Address - Street 1:140 GRANDVIEW AVE
Mailing Address - Street 2:SUITE 202 ASSOCIATED WOMENS HEALTH
Mailing Address - City:WATERBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06708
Mailing Address - Country:US
Mailing Address - Phone:203-755-2344
Mailing Address - Fax:203-573-8166
Practice Address - Street 1:140 GRANDVIEW AVE
Practice Address - Street 2:SUITE 202
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708
Practice Address - Country:US
Practice Address - Phone:203-755-2344
Practice Address - Fax:203-573-8166
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV114367A00000X
WV57006367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV9450001000Medicaid