Healthcare Provider Details

I. General information

NPI: 1104526391
Provider Name (Legal Business Name): LESLIE ANNE NEVILLE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 10/01/2026
Certification Date: 10/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 W 200 S APT 319
PROVO UT
84601-5917
US

IV. Provider business mailing address

136 W 200 S APT 319
PROVO UT
84601-5917
US

V. Phone/Fax

Practice location:
  • Phone: 209-581-8859
  • Fax:
Mailing address:
  • Phone: 209-581-8859
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number14240832-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: