Basic Information
| Provider Information | |||||||||
| NPI: | 1063435683 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GALLAGHER | ||||||||
| FirstName: | LESLIE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 696 | ||||||||
| Address2: | |||||||||
| City: | HAMPSTEAD | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284430696 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107916767 | ||||||||
| FaxNumber: | 9107916890 | ||||||||
| Practice Location | |||||||||
| Address1: | 311-4E JUDGES ROAD | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284053655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158999800 | ||||||||
| FaxNumber: | 4158999805 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2006 | ||||||||
| LastUpdateDate: | 03/29/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LG0600X | 11529 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology | 2084P0800X | 600013 | NC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 363L00000X | 600013 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7000774 | 05 | NC | MEDICAID | NP0115290 | 05 | CA | MEDICAID |