Provider Demographics
NPI:1700482163
Name:CLARK, LESLIE A (APRN)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:CLARK
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1730 DUNLAWTON AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32127-8986
Mailing Address - Country:US
Mailing Address - Phone:386-320-3299
Mailing Address - Fax:
Practice Address - Street 1:1730 DUNLAWTON AVE STE 1
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-8986
Practice Address - Country:US
Practice Address - Phone:386-320-3299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-12-09
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11009779363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner