Provider Demographics
NPI:1285890533
Name:RUSSELL, LESLIE ANNE
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:ANNE
Last Name:RUSSELL
Suffix:
Gender:F
Credentials:
Other - Prefix:MISS
Other - First Name:LESLIE
Other - Middle Name:ANNE
Other - Last Name:AGENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LPN
Mailing Address - Street 1:1310 SILVERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16505-5208
Mailing Address - Country:US
Mailing Address - Phone:814-838-4252
Mailing Address - Fax:
Practice Address - Street 1:1310 SILVERWOOD LN
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16505-5208
Practice Address - Country:US
Practice Address - Phone:814-838-4252
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-08-05
Last Update Date:2008-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN279110164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse