Healthcare Provider Details

I. General information

NPI: 1750586996
Provider Name (Legal Business Name): LESLIE JEAN HUMISTON APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 03/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS WAY # 840
LITTLE ROCK AR
72202-3500
US

IV. Provider business mailing address

1 CHILDRENS WAY # 840
LITTLE ROCK AR
72202-3500
US

V. Phone/Fax

Practice location:
  • Phone: 501-364-1100
  • Fax: 501-364-3960
Mailing address:
  • Phone: 501-364-1100
  • Fax: 501-364-3960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberA01733
License Number StateAR
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberA01733
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: