Provider Demographics
NPI:1407337504
Name:MUDGE, LESLIE MICHELLE (FNP)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:MICHELLE
Last Name:MUDGE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10TH MEDICAL GROUP
Mailing Address - Street 2:4102 PINON DRIVE
Mailing Address - City:USAF ACADEMY
Mailing Address - State:CO
Mailing Address - Zip Code:80840
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10TH MEDICAL GROUP
Practice Address - Street 2:4102 PINON DRIVE
Practice Address - City:USAF ACADEMY
Practice Address - State:CO
Practice Address - Zip Code:80840
Practice Address - Country:US
Practice Address - Phone:719-333-5186
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-27
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COAPN.0994106-NP363LF0000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily