Provider Demographics
NPI:1669972527
Name:GORRELL, LESLIE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:GORRELL
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 1:5673 PEACHTREE DUNWOODY RD STE 910
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1776
Mailing Address - Country:US
Mailing Address - Phone:404-255-3822
Mailing Address - Fax:
Practice Address - Street 1:5673 PEACHTREE DUNWOODY RD STE 910
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342
Practice Address - Country:US
Practice Address - Phone:404-255-3822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-17
Last Update Date:2020-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN239044363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily