Healthcare Provider Details

I. General information

NPI: 1700180767
Provider Name (Legal Business Name): LESLIE QUANDT-WALLE DVM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/06/2011
Last Update Date: 01/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3131 E THUNDERBIRD RD SUITE 59
PHOENIX AZ
85032-5600
US

IV. Provider business mailing address

1109 E NORTHWOOD DR
APPLETON WI
54911-1549
US

V. Phone/Fax

Practice location:
  • Phone: 602-787-0015
  • Fax:
Mailing address:
  • Phone: 480-209-2138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number5102-050
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code174M00000X
TaxonomyVeterinarian
License Number3800
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: