Provider Demographics
NPI:1952145658
Name:PAMUNGKAS, LESLIE KATHRYN (MSN, RN)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:KATHRYN
Last Name:PAMUNGKAS
Suffix:
Gender:F
Credentials:MSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:907 HANCOCK ST
Mailing Address - Street 2:
Mailing Address - City:PRAIRIE GROVE
Mailing Address - State:AR
Mailing Address - Zip Code:72753-2886
Mailing Address - Country:US
Mailing Address - Phone:479-713-0005
Mailing Address - Fax:
Practice Address - Street 1:907 HANCOCK ST
Practice Address - Street 2:
Practice Address - City:PRAIRIE GROVE
Practice Address - State:AR
Practice Address - Zip Code:72753-2886
Practice Address - Country:US
Practice Address - Phone:479-713-0005
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-19
Last Update Date:2025-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR069469163WE0003X
AR233191363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WE0003XNursing Service ProvidersRegistered NurseEmergency