Healthcare Provider Details

I. General information

NPI: 1962607234
Provider Name (Legal Business Name): LESLIE D BEALE PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/18/2007
Last Update Date: 04/14/2021
Certification Date: 04/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1129 6TH AVE
FORT WORTH TX
76104-4306
US

IV. Provider business mailing address

PO BOX 733784
DALLAS TX
75373-3784
US

V. Phone/Fax

Practice location:
  • Phone: 682-885-6248
  • Fax: 682-885-6249
Mailing address:
  • Phone: 682-885-1855
  • Fax: 682-885-1396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number658280
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: