Provider Demographics
NPI:1720355977
Name:DAVIS, LESLIE A (APRN)
Entity Type:Individual
Prefix:
First Name:LESLIE
Middle Name:A
Last Name:DAVIS
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:A
Other - Last Name:WHITAKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5607 DICKENSON HWY
Mailing Address - Street 2:
Mailing Address - City:CLINTWOOD
Mailing Address - State:VA
Mailing Address - Zip Code:24228-7099
Mailing Address - Country:US
Mailing Address - Phone:276-926-4601
Mailing Address - Fax:276-926-4602
Practice Address - Street 1:5607 DICKENSON HWY
Practice Address - Street 2:
Practice Address - City:CLINTWOOD
Practice Address - State:VA
Practice Address - Zip Code:24228
Practice Address - Country:US
Practice Address - Phone:276-926-4601
Practice Address - Fax:276-926-4602
Is Sole Proprietor?:No
Enumeration Date:2011-11-16
Last Update Date:2018-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3007214363L00000X
VA0024169761363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1720355977Medicaid