=====================================================
General NPI Number Information
=====================================================
NPI Number | 1750621561
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LESLI E. NALL PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/15/2013
-----------------------------------------------------
Last Update Date | 10/22/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1305 N ELM ST STE A
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42420-2783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-831-7937
-----------------------------------------------------
Fax | 270-831-7939
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1305 N ELM ST STE A
-----------------------------------------------------
City | HENDERSON
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42420-2783
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-831-7937
-----------------------------------------------------
Fax | 270-831-7939
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA1993
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA1993
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------