Provider Demographics
NPI:1811962392
Name:RATHBUN, LESLEY (CNM, FNP)
Entity type:Individual
Prefix:
First Name:LESLEY
Middle Name:
Last Name:RATHBUN
Suffix:
Gender:F
Credentials:CNM, FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9133 TIMBER STREET
Mailing Address - Street 2:
Mailing Address - City:NORTH CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29406
Mailing Address - Country:US
Mailing Address - Phone:843-818-1123
Mailing Address - Fax:843-818-1126
Practice Address - Street 1:9133 TIMBER STREET
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406
Practice Address - Country:US
Practice Address - Phone:843-818-1123
Practice Address - Fax:843-818-1126
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2008-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2133363LF0000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCMW0143Medicaid
SCQ23314Medicare UPIN
SCMW0143Medicaid