Provider Demographics
NPI:1780111468
Name:SULLIVAN, LESLIE N (DNP, APRN, PMHNP-BC)
Entity type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:N
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DNP, APRN, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 E 11TH ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:KY
Mailing Address - Zip Code:41071-2203
Mailing Address - Country:US
Mailing Address - Phone:859-655-6100
Mailing Address - Fax:
Practice Address - Street 1:1250 KEENE RD STE 104
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-7600
Practice Address - Country:US
Practice Address - Phone:859-881-4288
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-12
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011711363LP0808X
KY1094118363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100494780Medicaid