1598005654 NPI number — LESLIE GAYLE PHELPS ANCC

Table of content: LESLIE GAYLE PHELPS ANCC (NPI 1598005654)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598005654 NPI number — LESLIE GAYLE PHELPS ANCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PHELPS
Provider First Name:
LESLIE
Provider Middle Name:
GAYLE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ANCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
JAYNES
Provider Other First Name:
LESLIE
Provider Other Middle Name:
GAYLE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
NP
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1598005654
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/17/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2634
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORBIN
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40702-2634
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-280-4000
Provider Business Mailing Address Fax Number:
606-280-4051

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1013 MASTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORBIN
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
40701-1065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-280-4000
Provider Business Practice Location Address Fax Number:
606-280-4051
Provider Enumeration Date:
02/26/2013

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: 363L00000X , with the licence number:  3007920 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 7100243140 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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