Basic Information
Provider Information | |||||||||
NPI: | 1699176800 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | PELL | ||||||||
FirstName: | LESLIE | ||||||||
MiddleName: | MICHELL | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | NP.RN.CNP, APRN,PMHN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | EARLE | ||||||||
OtherFirstName: | LESLIE | ||||||||
OtherMiddleName: | MICHELLE | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | RN | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 720 ESKENAZI AVE | ||||||||
Address2: | FIFTH THIRD BANK BLDG, 5TH FL | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462025166 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3178804121 | ||||||||
FaxNumber: | 3178800343 | ||||||||
Practice Location | |||||||||
Address1: | 3171 N MERIDIAN ST | ||||||||
Address2: |   | ||||||||
City: | INDIANAPOLIS | ||||||||
State: | IN | ||||||||
PostalCode: | 462084784 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3179415003 | ||||||||
FaxNumber: | 3179315140 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/07/2014 | ||||||||
LastUpdateDate: | 11/12/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 02/22/2019 | ||||||||
NPIReactivationDate: | 03/18/2019 | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/12/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN.458718 | OH | N |   | Nursing Service Providers | Registered Nurse |   | 363LP0808X | 71005112B | IN | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | APRN.CNP.024210 | OH | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 71005112A | IN | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
No ID Information.