Provider Demographics
NPI:1700180767
Name:QUANDT-WALLE, LESLIE (DVM)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:QUANDT-WALLE
Suffix:
Gender:F
Credentials:DVM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1109 E NORTHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:APPLETON
Mailing Address - State:WI
Mailing Address - Zip Code:54911-1549
Mailing Address - Country:US
Mailing Address - Phone:480-209-2138
Mailing Address - Fax:
Practice Address - Street 1:3131 E THUNDERBIRD RD
Practice Address - Street 2:SUITE 59
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85032-5600
Practice Address - Country:US
Practice Address - Phone:602-787-0015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-06
Last Update Date:2011-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI5102-050174M00000X
AZ3800174M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174M00000XOther Service ProvidersVeterinarian