Provider Demographics
NPI:1588049878
Name:LESLIE, TAMMY JO
Entity type:Individual
Prefix:
First Name:TAMMY
Middle Name:JO
Last Name:LESLIE
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 1:4118 LINCOLN RD
Mailing Address - Street 2:
Mailing Address - City:STANDISH
Mailing Address - State:MI
Mailing Address - Zip Code:48658-9432
Mailing Address - Country:US
Mailing Address - Phone:989-359-9472
Mailing Address - Fax:
Practice Address - Street 1:4118 LINCOLN RD
Practice Address - Street 2:
Practice Address - City:STANDISH
Practice Address - State:MI
Practice Address - Zip Code:48658-9432
Practice Address - Country:US
Practice Address - Phone:989-359-9472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-28
Last Update Date:2015-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL240785420610171WH0202X
MI171WH0202X171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171WH0202XOther Service ProvidersContractorHome Modifications