Provider Demographics
NPI:1174149181
Name:LESLIE, ELLIOTT (LM, CPM)
Entity type:Individual
Prefix:
First Name:ELLIOTT
Middle Name:
Last Name:LESLIE
Suffix:
Gender:F
Credentials:LM, CPM
Other - Prefix:
Other - First Name:ELLIOTT
Other - Middle Name:
Other - Last Name:TILLMANN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LM, CPM
Mailing Address - Street 1:34617 11TH PL S STE 201
Mailing Address - Street 2:
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003-8706
Mailing Address - Country:US
Mailing Address - Phone:253-313-1031
Mailing Address - Fax:
Practice Address - Street 1:34617 11TH PL S STE 201
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-8706
Practice Address - Country:US
Practice Address - Phone:253-313-1031
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-25
Last Update Date:2022-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMW61127543176B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes176B00000XOther Service ProvidersMidwifeGroup - Single Specialty