1174550479 NPI number — LESLEE SUZANNE NASLUND

Table of content: LESLEE SUZANNE NASLUND (NPI 1174550479)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174550479 NPI number — LESLEE SUZANNE NASLUND

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NASLUND
Provider First Name:
LESLEE
Provider Middle Name:
SUZANNE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174550479
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/29/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 E 3RD ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DULUTH
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55805-1951
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
218-786-3443
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 E 3RD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
MN
Provider Business Practice Location Address Postal Code:
55805-1951
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
218-786-3443
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/26/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  R1162277 , registered in the state of MN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 43900600 , issued by the state of ( WI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 83519400 , issued by the state of ( MN ) . This identifiers is of the category "MEDICAID".