Healthcare Provider Details

I. General information

NPI: 1619981503
Provider Name (Legal Business Name): LESLIE CAROL ORTIZ PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2006
Last Update Date: 09/03/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 HOSPITAL DR STE 204
UKIAH CA
95482-4568
US

IV. Provider business mailing address

260 HOSPITAL DR STE 204
UKIAH CA
95482-4568
US

V. Phone/Fax

Practice location:
  • Phone: 707-463-7459
  • Fax: 707-468-9179
Mailing address:
  • Phone: 707-463-7459
  • Fax: 707-468-9179

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number416490
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: