=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205822053
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESLEY TODD CRNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/26/2005
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 120 BANJO LN
-----------------------------------------------------
City | CENTREVILLE
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21617-1002
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-758-1787
-----------------------------------------------------
Fax | 410-758-1789
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29466 PINTAIL DR SUITE 9
-----------------------------------------------------
City | EASTON
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21601-9323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 410-770-5140
-----------------------------------------------------
Fax | 410-770-5141
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP0808X
-----------------------------------------------------
Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
-----------------------------------------------------
License Number | R064855
-----------------------------------------------------
License Number State | MD
-----------------------------------------------------