Provider Demographics
NPI:1740302546
Name:BERRY, LESLIE NICOLE (PHARMD)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:NICOLE
Last Name:BERRY
Suffix:
Gender:F
Credentials:PHARMD
Other - Prefix:DR
Other - First Name:LESLIE
Other - Middle Name:NICOLE
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHARMD
Mailing Address - Street 1:953 AFTON ST
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-1173
Mailing Address - Country:US
Mailing Address - Phone:423-312-9257
Mailing Address - Fax:
Practice Address - Street 1:130 RAVINE ROAD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660
Practice Address - Country:US
Practice Address - Phone:423-224-6850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-04
Last Update Date:2010-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN23954183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist