Provider Demographics
NPI:1750621561
Name:NALL, LESLI E (PA-C)
Entity type:Individual
Prefix:MRS
First Name:LESLI
Middle Name:E
Last Name:NALL
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1305 N ELM ST STE A
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:KY
Mailing Address - Zip Code:42420-2783
Mailing Address - Country:US
Mailing Address - Phone:270-831-7937
Mailing Address - Fax:270-831-7939
Practice Address - Street 1:1305 N ELM ST STE A
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:KY
Practice Address - Zip Code:42420-2783
Practice Address - Country:US
Practice Address - Phone:270-831-7937
Practice Address - Fax:270-831-7939
Is Sole Proprietor?:No
Enumeration Date:2013-02-15
Last Update Date:2019-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA1993363A00000X, 363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100416580Medicaid