Provider Demographics
NPI:1265200950
Name:NGONG-NASSAH, LESLIE N (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:LESLIE
Middle Name:N
Last Name:NGONG-NASSAH
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5505.5 REISTERSTOWN RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21215
Mailing Address - Country:US
Mailing Address - Phone:443-493-7985
Mailing Address - Fax:
Practice Address - Street 1:12401 BRICKYARD BLVD APT 2106
Practice Address - Street 2:
Practice Address - City:BELTSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20705-1636
Practice Address - Country:US
Practice Address - Phone:240-374-8280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-13
Last Update Date:2024-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR215510363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health