Provider Demographics
NPI:1669190302
Name:GUILLORY, LESLIE SLEDGE (FNP)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:SLEDGE
Last Name:GUILLORY
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15601 ECORIO DR
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78728-3543
Mailing Address - Country:US
Mailing Address - Phone:512-963-2089
Mailing Address - Fax:
Practice Address - Street 1:630 W 34TH ST STE 301
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78705-1217
Practice Address - Country:US
Practice Address - Phone:512-212-4670
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-18
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1090301363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty