Provider Demographics
NPI:1306108576
Name:MARTIN, LESLIE S (CRNA)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:S
Last Name:MARTIN
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:B
Other - Last Name:SHANNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:PO BOX 288
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35804-0288
Mailing Address - Country:US
Mailing Address - Phone:256-880-6711
Mailing Address - Fax:256-880-6712
Practice Address - Street 1:721 MADISON ST SE
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-4408
Practice Address - Country:US
Practice Address - Phone:256-533-4888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-13
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-100496367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered