Basic Information
| Provider Information | |||||||||
| NPI: | 1598077398 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | OGILVY | ||||||||
| FirstName: | LESLIE | ||||||||
| MiddleName: | JEAN | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PA-C | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | MALAY | ||||||||
| OtherFirstName: | LESLIE | ||||||||
| OtherMiddleName: | JEAN | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PA-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1524 LAFAYETTE PKWY | ||||||||
| Address2: | |||||||||
| City: | LAGRANGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302412566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065302151 | ||||||||
| FaxNumber: | 7704606610 | ||||||||
| Practice Location | |||||||||
| Address1: | 1524 LAFAYETTE PKWY | ||||||||
| Address2: | |||||||||
| City: | LAGRANGE | ||||||||
| State: | GA | ||||||||
| PostalCode: | 302412566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7065302151 | ||||||||
| FaxNumber: | 7704606610 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2010 | ||||||||
| LastUpdateDate: | 08/21/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/21/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | PA.0004937 | CO | N | Allopathic & Osteopathic Physicians | Internal Medicine | 363A00000X | PA.0004937 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363A00000X | 9261 | GA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | MO4320797 | 01 | CO | DEA | OTHER | PA.0004937 | 01 | CO | MEDICAL LICENSE | OTHER | 9000158036 | 05 | CO | MEDICAID |