Healthcare Provider Details

I. General information

NPI: 1518726710
Provider Name (Legal Business Name): LESLEY PONCE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 03/18/2024
Certification Date: 03/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4950 MCNUTT RD
SUNLAND PARK NM
88008-9621
US

IV. Provider business mailing address

5852 MEGAN ST
SANTA TERESA NM
88008-5200
US

V. Phone/Fax

Practice location:
  • Phone: 575-882-6101
  • Fax:
Mailing address:
  • Phone: 915-316-7413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License NumberSLPCF23010
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: