Provider Demographics
NPI:1801487947
Name:LESLIE, MELISSA LYNN
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:LYNN
Last Name:LESLIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12790 DENNIS ST
Mailing Address - Street 2:
Mailing Address - City:PAULDING
Mailing Address - State:OH
Mailing Address - Zip Code:45879-8860
Mailing Address - Country:US
Mailing Address - Phone:419-769-9411
Mailing Address - Fax:
Practice Address - Street 1:12790 DENNIS ST
Practice Address - Street 2:
Practice Address - City:PAULDING
Practice Address - State:OH
Practice Address - Zip Code:45879-8860
Practice Address - Country:US
Practice Address - Phone:419-769-9411
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH376J00000XMedicaid