Provider Demographics
NPI:1699389304
Name:MOOSE, LESLIE ANNE
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:ANNE
Last Name:MOOSE
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 1:2798 JOHNSON HILL RD
Mailing Address - Street 2:
Mailing Address - City:SWAIN
Mailing Address - State:NY
Mailing Address - Zip Code:14884-9706
Mailing Address - Country:US
Mailing Address - Phone:607-590-6840
Mailing Address - Fax:
Practice Address - Street 1:401 N FAIRVIEW ST
Practice Address - Street 2:
Practice Address - City:LOCK HAVEN
Practice Address - State:PA
Practice Address - Zip Code:17745-2342
Practice Address - Country:US
Practice Address - Phone:570-484-2027
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-01
Last Update Date:2020-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer