Healthcare Provider Details

I. General information

NPI: 1114612785
Provider Name (Legal Business Name): SHANIA LESLIE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2023
Last Update Date: 07/25/2026
Certification Date: 07/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

177 SUMMIT AVE
HACKENSACK NJ
07601-1311
US

IV. Provider business mailing address

177 SUMMIT AVE
HACKENSACK NJ
07601-1311
US

V. Phone/Fax

Practice location:
  • Phone: 201-487-8222
  • Fax: 201-487-2126
Mailing address:
  • Phone: 201-487-8222
  • Fax: 201-487-2126

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA13125400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: