Healthcare Provider Details

I. General information

NPI: 1386100543
Provider Name (Legal Business Name): LESLIE NICOLE SPEEGLE BLAYLOCK CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/13/2019
Last Update Date: 04/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 DANA RD
WARRIOR AL
35180-1420
US

IV. Provider business mailing address

100 DANA RD
WARRIOR AL
35180-1420
US

V. Phone/Fax

Practice location:
  • Phone: 205-647-6333
  • Fax: 205-647-8666
Mailing address:
  • Phone: 205-647-6333
  • Fax: 205-647-8666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-153505
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: