MEDICARE: LESLIE KIDD

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	163WH0200X	Home Health Registered Nurse	4704260532	MI

General Provider Information

NPI Number	:	1568095222
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LESLIE KIDD

Provider Business Mailing Address
First Line	:	3097 PRAIRIE ST SW
Second Line	:
City	:	GRANDVILLE
State	:	MI
Zip	:	49418-2000
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8904 CEDAR LAKE DR
Second Line	:
City	:	JENISON
State	:	MI
Zip	:	49428-9462
Country	:	US
Telephone Number	:	616-443-7934
Fax Number	:

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

Provider Enumeration Date	:	02/20/2020
Last Update Date	:	02/20/2020

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Directions to “ LESLIE KIDD ” Practice Location

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