Provider Demographics
NPI:1821581547
Name:MCQUEEN, LESLIE RENEE' (APRN)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:RENEE'
Last Name:MCQUEEN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3916 HAMILTON VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:CRAB ORCHARD
Mailing Address - State:KY
Mailing Address - Zip Code:40419-9659
Mailing Address - Country:US
Mailing Address - Phone:859-339-4414
Mailing Address - Fax:
Practice Address - Street 1:613 MAIN ST
Practice Address - Street 2:
Practice Address - City:CRAB ORCHARD
Practice Address - State:KY
Practice Address - Zip Code:40419-6520
Practice Address - Country:US
Practice Address - Phone:606-370-4011
Practice Address - Fax:606-370-4012
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-07
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012230363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
14271226OtherCAQH
KY7100560000Medicaid