Healthcare Provider Details

I. General information

NPI: 1376793349
Provider Name (Legal Business Name): LESLEY JO ALLEN APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LESLEY BROCK

II. Dates (important events)

Enumeration Date: 09/25/2008
Last Update Date: 07/18/2024
Certification Date: 07/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1640 FLOSSIE DR
GREENDALE IN
47025-8424
US

IV. Provider business mailing address

560 S LOOP RD
EDGEWOOD KY
41017-3405
US

V. Phone/Fax

Practice location:
  • Phone: 812-496-3285
  • Fax: 812-537-0400
Mailing address:
  • Phone: 859-301-2663
  • Fax: 859-301-0655

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCOA.10389-NP
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3005659
License Number StateKY
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number71015390A
License Number StateIN
# 4
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number3005659
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: