Healthcare Provider Details

I. General information

NPI: 1225198781
Provider Name (Legal Business Name): LESLIE M POWELL NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 05/13/2020
Certification Date: 05/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR
SAN DIEGO CA
92103-9000
US

IV. Provider business mailing address

3900 W COAST HWY SUITE 310
NEWPORT BEACH CA
92663-4091
US

V. Phone/Fax

Practice location:
  • Phone: 800-926-8273
  • Fax: 188-853-9878
Mailing address:
  • Phone: 949-478-8858
  • Fax: 949-242-2465

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95005257
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95005257
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number95005257
License Number StateCA
# 4
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number95005257
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: