Healthcare Provider Details

I. General information

NPI: 1114400256
Provider Name (Legal Business Name): LESLIE MARIE KENNEDY NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LESLIE MARIE THEISEN

II. Dates (important events)

Enumeration Date: 09/14/2018
Last Update Date: 04/13/2026
Certification Date: 04/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BROAD ST
CENTRAL FALLS RI
02863-1507
US

IV. Provider business mailing address

39 EAST AVE
PAWTUCKET RI
02860-4003
US

V. Phone/Fax

Practice location:
  • Phone: 401-722-0081
  • Fax:
Mailing address:
  • Phone: 401-312-5247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN04983
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN0997082NP
License Number StateCO
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209018394
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704347248
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: