Provider Demographics
NPI:1669898912
Name:BRUNDAGE, LESLIE SMITH (RNC,IBCLC RLC)
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:SMITH
Last Name:BRUNDAGE
Suffix:
Gender:F
Credentials:RNC,IBCLC RLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43768 JENKINS LN
Mailing Address - Street 2:
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-4822
Mailing Address - Country:US
Mailing Address - Phone:703-723-6621
Mailing Address - Fax:703-723-7877
Practice Address - Street 1:43768 JENKINS LN
Practice Address - Street 2:
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-4822
Practice Address - Country:US
Practice Address - Phone:703-723-6621
Practice Address - Fax:703-723-7877
Is Sole Proprietor?:No
Enumeration Date:2014-03-11
Last Update Date:2014-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001172419163WL0100X
VAL-42144163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant