Provider Demographics
NPI:1952107690
Name:LESLIE, EDDISSIA KAMAYLAH
Entity type:Individual
Prefix:
First Name:EDDISSIA
Middle Name:KAMAYLAH
Last Name:LESLIE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:504 COLLEGE DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31705-2796
Mailing Address - Country:US
Mailing Address - Phone:229-500-2000
Mailing Address - Fax:
Practice Address - Street 1:504 COLLEGE DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31705-2717
Practice Address - Country:US
Practice Address - Phone:229-500-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-24
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA2255A2300X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer