Provider Demographics
NPI:1427513415
Name:KING, LESLIE (APRN)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:
Last Name:KING
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:1350 CEDAR CT
Mailing Address - Street 2:
Mailing Address - City:CARBONDALE
Mailing Address - State:IL
Mailing Address - Zip Code:62901-5336
Mailing Address - Country:US
Mailing Address - Phone:618-529-2955
Mailing Address - Fax:618-457-7823
Practice Address - Street 1:1350 CEDAR CT
Practice Address - Street 2:
Practice Address - City:CARBONDALE
Practice Address - State:IL
Practice Address - Zip Code:62901-5336
Practice Address - Country:US
Practice Address - Phone:618-529-2955
Practice Address - Fax:859-721-3913
Is Sole Proprietor?:No
Enumeration Date:2019-02-05
Last Update Date:2022-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041383352163W00000X
KY3016320363LW0102X
IL209018931363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health