MEDICARE: LESLEY DAWN OUTLAW NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	RN268135	GA

General Provider Information

NPI Number	:	1659157303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLEY DAWN OUTLAW NP

Provider Business Mailing Address
First Line	:	623 S HOUSTON LAKE RD STE 500
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31088-9094
Country	:	US
Telephone Number	:	478-333-6977
Fax Number	:

Provider Business Practice Location Address
First Line	:	623 S HOUSTON LAKE RD STE 500
Second Line	:
City	:	WARNER ROBINS
State	:	GA
Zip	:	31088-9094
Country	:	US
Telephone Number	:	478-333-6977
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2023
Last Update Date	:	09/07/2023

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