Healthcare Provider Details

I. General information

NPI: 1245462811
Provider Name (Legal Business Name): LESLEY JOHNSEN DAC, LAC, MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2009
Last Update Date: 07/21/2022
Certification Date: 07/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

99 E VIRGINIA AVE STE 170
PHOENIX AZ
85004-1124
US

IV. Provider business mailing address

99 E VIRGINIA AVE STE 170
PHOENIX AZ
85004-1124
US

V. Phone/Fax

Practice location:
  • Phone: 480-717-7838
  • Fax:
Mailing address:
  • Phone: 480-717-7838
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number0977
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: