Healthcare Provider Details

I. General information

NPI: 1861093825
Provider Name (Legal Business Name): LESLEY ROLLER CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/05/2020
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4901 LANG AVE NE
ALBUQUERQUE NM
87109-4397
US

IV. Provider business mailing address

4901 LANG AVE NE
ALBUQUERQUE NM
87109-4397
US

V. Phone/Fax

Practice location:
  • Phone: 505-842-8171
  • Fax:
Mailing address:
  • Phone: 505-842-8171
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number61963
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: