Provider Demographics
NPI:1194272435
Name:MEAD, LESLIE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:MEAD
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 1:1600 N MAIN AVE
Mailing Address - Street 2:
Mailing Address - City:LOVINGTON
Mailing Address - State:NM
Mailing Address - Zip Code:88260-2813
Mailing Address - Country:US
Mailing Address - Phone:575-396-6611
Mailing Address - Fax:
Practice Address - Street 1:6934 SW 93RD RD
Practice Address - Street 2:
Practice Address - City:BUSHNELL
Practice Address - State:FL
Practice Address - Zip Code:33513-8314
Practice Address - Country:US
Practice Address - Phone:352-457-1401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-03
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM73391363LF0000X
FLARNP9213825363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily