MEDICARE: MS. LESLIE MARIE MOFRAD RN , MSN, CPNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0200X	Pediatric Nurse Practitioner	4704201928	MI

General Provider Information

NPI Number	:	1508138033
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. LESLIE MARIE MOFRAD RN , MSN, CPNP

Provider Business Mailing Address
First Line	:	2331 MONROE ST
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48124-3009
Country	:	US
Telephone Number	:	313-792-0345
Fax Number	:	313-792-0346

Provider Business Practice Location Address
First Line	:	2331 MONROE ST
Second Line	:
City	:	DEARBORN
State	:	MI
Zip	:	48124-3009
Country	:	US
Telephone Number	:	313-792-0345
Fax Number	:	313-792-0346

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/30/2012
Last Update Date	:	01/30/2012

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