Provider Demographics
NPI:1063435683
Name:GALLAGHER, LESLIE (NP)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:GALLAGHER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 696
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-0696
Mailing Address - Country:US
Mailing Address - Phone:910-791-6767
Mailing Address - Fax:910-791-6890
Practice Address - Street 1:311-4E JUDGES ROAD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405-3655
Practice Address - Country:US
Practice Address - Phone:415-899-9800
Practice Address - Fax:415-899-9805
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2011-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11529363LG0600X
NC6000132084P0800X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7000774Medicaid
CANP0115290Medicaid
NC2592774AMedicare PIN
NC7000774Medicaid
CAZZZ23366ZMedicare ID - Type Unspecified