Provider Demographics
NPI:1487990503
Name:SMITH, LESLIE (ARNP-BC)
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:
Last Name:SMITH
Suffix:
Gender:F
Credentials:ARNP-BC
Other - Prefix:
Other - First Name:LESLIE
Other - Middle Name:
Other - Last Name:GILLIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1202 PALMER TER
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-8939
Mailing Address - Country:US
Mailing Address - Phone:813-541-8911
Mailing Address - Fax:
Practice Address - Street 1:12675 BEACH BLVD #101
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32246
Practice Address - Country:US
Practice Address - Phone:904-204-1541
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-18
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9203170363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health