Provider Demographics
NPI:1700877784
Name:MORTIMER, LESLEY JOAN (CNP)
Entity Type:Individual
Prefix:MS
First Name:LESLEY
Middle Name:JOAN
Last Name:MORTIMER
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4221 SADDLEWOOD TRL SE
Mailing Address - Street 2:
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-8205
Mailing Address - Country:US
Mailing Address - Phone:505-892-1310
Mailing Address - Fax:505-892-6843
Practice Address - Street 1:1217 1ST ST NW
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87125
Practice Address - Country:US
Practice Address - Phone:505-767-1118
Practice Address - Fax:505-242-3531
Is Sole Proprietor?:No
Enumeration Date:2005-10-31
Last Update Date:2008-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMR15653363LF0000X
WARN00081985363LF0000X
WAAP30001222363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM45385Medicaid