Provider Demographics
NPI:1598589251
Name:LOMACK, LESLIE MICHELLE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:MICHELLE
Last Name:LOMACK
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 1:1327 6TH ST E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55106-4734
Mailing Address - Country:US
Mailing Address - Phone:507-338-3478
Mailing Address - Fax:
Practice Address - Street 1:1327 6TH ST E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55106-4734
Practice Address - Country:US
Practice Address - Phone:507-338-3478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-11
Last Update Date:2024-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNCFSSPCA1330265202411374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide