Provider Demographics
NPI:1750495610
Name:O'CONNOR, LESLIE HETZEL (APRN, BC)
Entity type:Individual
Prefix:MRS
First Name:LESLIE
Middle Name:HETZEL
Last Name:O'CONNOR
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 DEAN DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH GLASTONBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06073-3301
Mailing Address - Country:US
Mailing Address - Phone:860-659-9532
Mailing Address - Fax:
Practice Address - Street 1:YALE- NEW HAVEN HOSPITAL
Practice Address - Street 2:20 YORK STREET
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06504
Practice Address - Country:US
Practice Address - Phone:203-688-9216
Practice Address - Fax:203-688-9709
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001566364SP0808X, 364SP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0809XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health, Adult
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT890000290Medicare ID - Type Unspecified