Healthcare Provider Details

I. General information

NPI: 1255484382
Provider Name (Legal Business Name): LESLIE ELLEN MCGILL-MAYOTTE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LESLIE ELLEN MCGILL NP

II. Dates (important events)

Enumeration Date: 01/20/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

26755 BALLARD ST
HARRISON TOWNSHIP MI
48045-2419
US

IV. Provider business mailing address

4485 RIVERCHASE DR
TROY MI
48098-5429
US

V. Phone/Fax

Practice location:
  • Phone: 586-466-5501
  • Fax:
Mailing address:
  • Phone: 248-792-4143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number4704217031
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4704217031
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: