Provider Demographics
NPI:1417763632
Name:WALLACE, LESLEY DIANE
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:DIANE
Last Name:WALLACE
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 1:1103 E MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:AR
Mailing Address - Zip Code:72560-4007
Mailing Address - Country:US
Mailing Address - Phone:870-200-6995
Mailing Address - Fax:
Practice Address - Street 1:1103 E MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:AR
Practice Address - Zip Code:72560-4007
Practice Address - Country:US
Practice Address - Phone:870-200-6995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-04
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR216734163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse