Healthcare Provider Details

I. General information

NPI: 1467771758
Provider Name (Legal Business Name): LESLIE A KOLTES NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/26/2010
Last Update Date: 12/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 1ST AVE S
FARGO ND
58103-1899
US

IV. Provider business mailing address

700 1ST AVE S
FARGO ND
58103-1899
US

V. Phone/Fax

Practice location:
  • Phone: 701-234-4036
  • Fax:
Mailing address:
  • Phone: 701-234-4036
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR30767
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: